LIBRARY OF CONGRESS. 



%$t + -.- ©xi{a?ri# 

Shelf JA.3__._ 

1 ^ + 

UNITED STATES OF AMERICA. 



t 



PLATE I. 



Fig 1. 



Fig. 2. 




Tubercle Bacilli. B. Pneumococcus. A. Anthrax. B. Streptococcus and Staphylococcus. 



Fig. 3. Fig. 4. 




. Comma Bacillus. B. Gonococcus. A. Recurrent Spirilla. B. Leprosy. 




Normal Blood. B. Normal Blood. 



A. Leukaemia. 



B. Eberth's Bacillus. 



PRACTICAL TREATISE 



ON 



MEDICAL DIAGNOSIS 



FOR STUDENTS AND PHYSICIANS. 



BY 



JOHN H. MUSSER, M.D. 



ASSISTANT PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA; PHYSICIAN 
TO THE PHILADELPHIA AND THE PRESBYTERIAN HOSPITALS ; CONSULTING PHYSICIAN TO THE 
WOMEN'S HOSPITAL OF PHILADELPHIA AND TO THE WEST PHILADELPHIA HOSPITAL FOR 
WOMEN ; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA J MEMBER 
OF THE ASSOCIATION OF AMERICAN PHYSICIANS ; PRESIDENT OF THE 
PATHOLOGICAL SOCIETY OF PHILADELPHIA, ETC. 



ILLUSTRATED WITH 16% WOODCUTS AND 2 COLORED PLATES. 




OF 

FEf 8018M 

//OS*/*- 



PHILADELPHIA: 

LEA BROTHERS & CO. 
1 894. 



Entered according to the Act of Congress, in the year 1894, by 
LEA BROTHERS & CO., 
In the Office of the Librarian of Congress, at Washington. All rights reserved. 



LC Control Number 



DOENAN, PRINTER. 

tmp96 029100 




TO THE 
MEMORY OF MY FATHER 

BENJAMIN MUSSER, M. 

AND 

MY GRANDFATHER 

MARTIN MUSSER, M.D. 



PREFACE. 



Modern methods of medical education demand that the student 
should be taught the expressions of morbid action , or, in other words, 
the phenomena of disease. He must be brought into contact with 
them in the hospital ward and the out-patient room, which are the 
medical laboratories where all the data are collected, analyzed, and 
used in discriminating the various disorders. 

The object of this volume is to aid the student in the pursuit of 
such laboratory studies, and at the same time to furnish the prac- 
titioner with a reliable practical guide to diagnosis for use in his 
daily work. It has been thought best to combine in these pages the 
study of the objective phenomena or signs of disease, the subjective 
phenomena or symptoms, and the methods employed for their deter- 
mination. Special attention has been paid to research for objective 
phenomena appearing in physical, chemical, and biological changes in 
the tissues and secretions. The necessity for elaborate descriptions 
or extended lists of minutiae as guides to differentiation is being 
rapidly displaced by the use of instruments of precision. Formerly, 
for instance, extensive tables were displayed to indicate the differential 
diagnostic features of anaemia and chlorosis ; now a few moments' ex- 
amination of the blood decides the nature of the affection and whether 
iron or arsenic is to be given for its cure. 

The following pages bear evidence that the author does not under- 
value the direct and collateral data obtained by inquiry. Without 
them an examination carefully conducted according to all other 
methods may go for naught in the distinction of disease. 

The association of morbid processes with their phenomena is a 
practice of the utmost importance to students, and a chapter has 
therefore been inserted upon the Symptomatology of Morbid Pro- 
cesses. Bacteriological Diagnosis has become an established method 



vi 



PREFACE. 



by which various disorders are recognized, and it is essential that the 
procedures in this new means of research should be fully outlined. 
The chapter on this subject is included not merely as a guide and 
reference for the trained student, but it is hoped that it will also 
emphasize the possibilities of bacteriological studies and inspire those 
who are themselves without facilities for prosecuting laboratory work 
to have examinations made for diagnostic purposes by experts with 
laboratories at their command. 

My best thanks are due to my associate in private and hospital 
work and teaching, Dr. H. B. Allyn, for assistance without which 
this book could not have been written ; to Dr. H. Toulmin for aid in 
the collaboration of the sections devoted to the examination of Sputum 
and Faeces ; to Dr. Charles Burr, of the Infirmary for Nervous 
Diseases, for the articles on Cerebral and Spinal Localization and on 
Electrical Diagnosis, and to Drs. Joseph Sailer, W. H. Fenn, and 
J. E. Talley, for valuable assistance. 



Fortieth and Locust Streets, Philadelphia, 
February, 1894. 



CONTENTS. 



PART I. 

GENERAL DIAGNOSIS. 
CHAPTER I. 

PAGES 

General Observations 17-23 

CHAPTER II. 

The Data Obtained by Inquiry 24-48 

CHAPTER III. 

The Data Obtained by Observation 49-144 

CHAPTER IV. 

Bacteriological Diagnosis 145-158 

CHAPTER V. 

The Examination of Exudations, Transudations, and Cystic 

Fluids 159-170 

CHAPTER VI. 

The Morbid Processes and their Symptomatology . . .171-186 



PART II. 

SPECIAL DIAGNOSIS. 
CHAPTER I. 

Diseases of the Nose and Larynx 187-221 

CHAPTER II. 

Diseases of the Lungs and Pleura 222-337 



viii 



CONTENTS. 



CHAPTER III. 

PAGES 

Diseases of the Heart, the Bloodvessels, and the Media- 
stinum . . . • 338-429 

CHAPTER IY. 

Diseases of the Mouth, Fauces, Pharynx, and (Esophagus . 430-466 

CHAPTER V. 

Diseases of the Stomach, Intestines, and Peritoneum . . 467-583 

CHAPTER VI. 

Diseases of the Liver, Spleen, and Pancreas .... 584-626 

CHAPTER VII. 

Diseases of the Kidneys 627-682 

CHAPTER VIII. 

Diseases of the Blood and Ductless Glands .... 683-704 

CHAPTER IX. 

Constitutional Diseases 705-722 

CHAPTER X. 

The Infectious Diseases 723-786 

CHAPTER XI. 

Diseases of the Nervous System 787-860 



MEDICAL 



DIAGNOSIS. 



PART I. 

GENERAL DIAGNOSIS. 



CHAPTEE I. 

GENERAL OBSERVATIONS. 

The data upon which a diagnosis is based : The data obtained by inquiry. The data 
obtained by observation. — Object of diagnosis. — Requirements on the part of 
the student. — Methods of diagnosis: Direct. Indirect (by exclusion). Dif- 
ferential. — Diagnosis sometimes impossible. Avoid haste. — Diagnosis should not 
be limited. — Modern diagnosis. — Case record. — Scope of the present volume. 

The sufferings of one who comes under the care of a physician are 
indicated by symptoms of which the patient himself is cognizant, and 
for which usually he applies for relief; or by alterations of the physical or 
chemical structure of the whole or a part of the body, or of the functional 
activity of organs — alterations which, although not apparent to him, 
are evident to the observer, the physician. The symptoms of which the 
patient complains, and of which he alone has knowledge, are known as 
the subjective symptoms of disease. The symptoms which the physician 
observes, some of which, as the changes of the exterior surface, may be 
apparent to the patient, are known as the objective symptoms of disease. 

The subjective symptoms of disease, as well as such objective symp- 
toms as the patient is aware of, have a history. It may be the brief 
one of sudden onset, or a long one of rise and fall, of ebb and flow, of 
the mingling of complex phenomena from time to time. The story 
of the evolution of the disease is written as the history of the present 
disease. 

The present disease may be due to previous attacks of disease, or be 
modified by the occurrence of previous disease. We may be consulted 
for the effects of one link in a chain of morbid disorder which began 
in early infancy or adult life. We should learn, therefore, of the occur- 
rence of previous disease. Certain types of constitution and some few 
diseases are transmitted by parents to offspring, and, therefore, in a 
consideration of the patient's suffering we should inquire into the family 
history. A further insight into the nature of the suffering may be 

2 



18 



GENERAL DIAGNOSIS. 



obtained by a knowledge of the age, sex, habits, occupation, environ- 
ment, etc. — in short, by a knowledge of the social history. For, if the 
cause of the disease under consideration is determined, frequently a 
distinction from other affections with allied phenomena can be made. 

The subjective symptoms, the history of the present disease, the previous 
history, the family history, and the social history are learned by inquiry 
of the patient or the friends of the patient by means and within limita- 
tions hereafter to be described. It is proper that they should be ascer- 
tained, if practicable, before the objective symptoms are studied. 

After the story of the patient is ascertained in full, the objective 
symptoms are sought for. Examination of the patient by the use of 
the senses of sight, of touch, of hearing, with the instruments of pre- 
cision to aid them — the physical examination — and by chemical and 
bacteriological methods, reveals the presence or absence of the latter 
class of symptoms. 

The phenomena of disease are ascertained, therefore, by inquiry and 
by observation. The facts or data thus collected and the discriminate 
interpretation of them constitute diagnosis. 

Object of Diagnosis. The object of diagnosis is to determine the 
condition of the living patient who may be suffering from disease. It 
implies not only that the phenomena of disease are detected, but also 
that the effects of the disease on the organism are determined, and that 
the morbid process which is the cause of the phenomena is ascertained. 
Even this is too restricted an idea of diagnosis. It should include also 
the recognition of the cause of the morbid process. The latter is known 
as the cetiological diagnosis. 

Diagnosis is not made in order to give a disease a name, but to treat 
it, and as it is not disease that we treat, but a patient with an ailment, full 
knowledge of the patient and of his environment, his mode of life, habits, 
occupation, etc., must be obtained by inquiry. 

The practical result of diagnosis is the ability to remove or prevent 
the occurrence of the morbid processes, or to mitigate their effects by 
rational therapeutics. 

Requisites on the Part of the Student. As data are to be 
collected by inquiry and by observation, it is obvious that he who 
would inquire and observe intelligently and successfully must be 
possessed of knowledge and qualifications of a high order. The phe- 
nomena of health must be familiar to him. He must have a full 
knowledge of physiology to recognize aberrations of function, and of 
pathology to understand the production of symptoms by disease. He 
must know the organic results of morbid processes — pathological anat- 
omy. He must have learned by reading and experience the significance 
of symptoms or of groups of symptoms and their relation to morbid 
processes. 

He must have a knowledge of the evolution of disease and the phe- 
nomena of each period in its development to secure an accurate account 
of the disease under consideration. He must know the influence of 
morbid processes on the body and their effect in the production of sub- 



GENERAL OBSERVATIONS. 



19 



sequent disease, in order to ascertain correctly the various diseases of 
the patient and infer rightly their relation to the phenomena under con- 
sideration. The significance of the family history can be appreciated 
and correctly applied only by a knowledge of the diseases which are 
inherited or which arise in certain physical types of individuals, which 
type is inherited. The social history is not worth securing unless the 
inquirer knows the influence of age and sex, of race, of occupation, of 
habits, of residence, of degree of labor, in the development of disease, 
or the influence of the environment on the individual — the action and 
reaction of external forces on forces within. 

To ascertain the objective symptoms, he who would observe properly 
must know anatomy to recognize the seat of disease, and physiology to 
know the departures from health. He must be trained at the bedside 
in the use of the senses, and know how to discriminate and interpret 
phenomena observed by them. He must know how to use instruments 
of precision, as the microscope, and must learn its revelations ; the 
laws of chemistry and the methods of chemical examination must be 
familiar to him. Bacteriology and the data derived by its methods 
must be appreciated fully. 

It is thus seen that the inquirer must have knowledge largely gained 
by reading, by which he acquires the recorded experience of others and 
learns that certain symptoms under certain circumstances indicate a 
definite malady, and by observation at the bedside and in the post- 
mortem room, by which he learns that certain symptoms are associated 
with definite lesions. 

Methods of Diagnosis. But we must not only secure facts, but be 
able to utilize them for analysis and induction — the result of which is 
the formation of the diagnosis. The diagnosis is obtained by three 
methods — the direct, the indirect, and the differential. By the direct 
method the data collected are sufficient to warrant a positive conclusion. 
An indirect diagnosis is made by exclusion. A symptom group may 
represent several diseases. Each affection is passed in review and 
excluded until one is found to correspond more closely to the data. 
It is not one, because of the absence of certain symptoms ; it is not 
another, because of the presence of certain essentially different symp- 
toms. A negative is thereby proven. By the differential method the 
diagnosis of one of a few possible diseases must be made, the data for 
and against which are passed in review. The direct method is scientific 
and the most satisfactory. 

Diagnosis sometimes Impossible. Notwithstanding our efforts to 
collect data by inquiry and by observation, we are often unable to make 
a diagnosis. This arises because premises are wanting in the induction. 
The subjective symptoms may not tally with the known processes of 
disease, or the narrator of the history of the present disease may omit 
important evidence from lack of memory or knowledge, from design, or 
for other reasons. The objective phenomena may have developed in an 
ill-defined way, or are obscure, as the state of the abdominal contents in 
obesity, or they may point to one or more processes the subjective symp- 



20 



GENERAL DIAGNOSIS. 



toros of which are not present. At the time of observation the disease 
may not have developed fully, may not have " spelled itself out," as in 
the early stages of the exanthemata. Under these circumstances a pro- 
visional diagnosis must be made or conclusions held in abeyance. If we 
are considering a contagious disease, for sanitary reasons all doubt 
should be settled in favor of the infectious disease. If, on the other 
hand, the disease requires prompt remedial action, the symptoms must 
be taken as the indication for therapy. 

Avoid haste. If prompt action is not required, too great haste should 
be avoided. It is not necessary to make a diagnosis at once, and it is 
not a confession of ignorance if time is asked before an opinion is 
given. Repeated observation and reflection should be employed before 
a conclusion is arrived at. This particularly applies to the class of 
cases which represent a condition the resultant of an improper environ- 
ment, for the proper detection of which social data, knowledge of 
temperament, etc., must be acquired. Then, again, it may be necessary 
to observe the patient under changed circumstances, or study the effects 
of diet on renal secretion, or on the function of other organs. Haste 
leads to faulty diagnosis, and therefore to misdirected therapeusis. 

Diagnosis should Not be Limited. It is not sufficient to give a 
name to a group of symptoms, and be satisfied that the diagnosis is 
made. Every method must be used to collect data. The exact phys- 
ical condition of the patient must be ascertained and the functional 
powers of all the organs correctly determined. We thus learn if the 
more evident disease is the single expression of a morbid process or if it 
is the surface storm, the currents of which are underneath. A pleurisy 
or pneumonia may be the outcome of or complicate a latent nephritis. 
A peritonitis may be the sequela of an appendicitis or pyosalpinx. Or 
disease in two or more organs, due to the same process, may exist at 
the same time, as suppurative pleuritis and pericarditis. It would not 
be sufficient to recognize the empyema alone. 

For purposes of treatment it is not sufficient to recognize a neuralgia 
or a spasm. The state of the patient on account of which the neu- 
ralgia developed must be ascertained. Attention must be called to the 
importance of not being lulled into a false security by the belief that 
the diagnosis of the first day is sufficient. Complications may arise 
or the morbid process invade new territory. Thus, in the course of 
pneumonia, in a few days a meningitis may arise, or an ulcerative 
endocarditis ensue. 

Modern Diagnosis. Anyone who takes the trouble to recall the 
methods of diagnosis that were in use twenty years ago will be struck 
by the wonderful expansion of the means now at hand to unravel the 
mysteries of disease. Then a few instruments of precision and a few chem- 
ical reagents were required. The microscope was employed to examine 
a few of the excretions and the blood only. Now the instruments of 
precision are multiplied and the scope of their explorations increased. 1 

1 As a most simple illustration, witness the knee-jerk and reflexes, learned by an old method., 
percussion, in extended use. 



GENERAL OBSERVATIONS. 



21 



Chemistry, among other things, helps to fathom the mysteries of gastric 
disease. The domain of the microscope has increased, and with the 
new methods of staining fluids and tissues, is the key that unlocks 
many of Nature's secrets. The new science of bacteriology has come to 
our aid, and now, before waiting until an epidemic counts its victims 
by hundreds to establish a diagnosis, it is at once attained. 

Certainty in diagnosis, for these reasons, has made a decided advance. 
The number of diseases which can positively be diagnosticated has 
increased. Methods of investigation and new instruments of precision 
are daily on the increase. May we not hope that in the future the 
horizon of absolute knowledge will be extended far beyond the present? 
New instruments and new methods will surely avail. 

The use of the large number of instruments that are essential, and 
the chemical and bacteriological examinations that are made, require a 
great deal of time. Often the diagnosis is a question of hours or even 
of days. The patient profits thereby. The tax on the physician is far 
greater than a few years ago. The bedside labor is great, and in addi- 
tion he must have a laboratory at his command for microscopical, chem- 
ical, and bacteriological work. The outcome is that the scientific physician 
must have a clientele limited in number, or else have one or more assist- 
ants to aid in his investigations. Without doubt the latter will soon 
occur. Not as in days of old will we find in the practitioner's office the 
apprentice, compounding drugs and rolling bandages, assisting in the 
operation of bleeding and dressing ulcers, but the highly trained, scien- 
tific assistant who by labors in the laboratory and at the bedside is com- 
petent to collect data suitable for scientific methods of reasoning. 

Case Records. Records of cases should be kept, for many obvious 
reasons. The habit compels a general survey of the case, and tends to 
prevent oversight in the examination. It naturally aids in the training 
of the powers of observation. It teaches precision in the narration of 
cases. The memory is aided by repetition and by lack of haste in 
ascertaining phenomena. The data are on record for more mature 
reflection, and to aid in a study of the literature of similar cases. The 
record is of value in case the patient returns for advice after a lapse of 
time. It may be of medico-legal value. The mental effect on the 
patient is good, for the taking of notes requires time and accurate 
studied observation. In case it is desired to study a large number of 
cases, records are scientific data. The records may be kept on loose 
sheets and filed for future use. When a sufficient number are secured 
they may be bound in volumes devoted to the respective disease. Or 
they may be noted in a blank-book selected for the purpose. At the end 
of the year the book is indexed according to the diseases and the names 
of the patients. A better method is by a system of cards. The card- 
board should be six by eight inches. One card is devoted to each case, 
although more can be used. They are arranged and catalogued accord- 
ing to the library system of card catalogues. 

Method of Record. A systematic plan must be pursued in noting 
the cases. It need not correspond to the lines of inquiry in the examina- 
tion of the patient, which are modified by the circumstances of the case. 



22 



GENERAL DIAGNOSIS. 



The social history, the family history, previous diseases, the history of 
the present disease, including the mode of onset and the duration of the 
disease, should be recorded in regular sequence. In the history of the 
present disease the subjective and objective symptoms should be recorded 
in order. The subjective symptoms that refer to special systems or 
organs, and the objective symptoms of the same, should be recorded 
under the special heading. 



RECORD OF CASE NO. — 

Diagnosis. Result. 

Name and residence, place of birth, and former residence. 

Social history. 

Age, sex, race, married or single. 
Occupation : Present and previous. 

Habits : Tobacco, alcohol, narcotics ; sexual habits ; regularity of meals, 
character of food, and method of eating ; number of hours of sleep, degree of 
fatigue ; brain use. 

Family history : Hereditary tendency ; health of parents, brothers, sisters, etc. 
Cause of death and age at which it occurred. 

Personal history : Children, the number and health ; miscarriages. 

Previous diseases : Character of convalescence ; syphilis and gonorrhoea ; in- 
juries. 

Present disease : Date, mode of onset, and probable exciting cause of present 
trouble ; evolution of the disease to date of examination. 

Present condition : Subjective symptoms. 
Objective symptoms. 

External appearance, development, color, figure, height and weight, attitude, 
expression of face. 

Temperature, perspiration, eruption, swelling. Condition of limbs and joints. 

Examination of the digestive apparatus : Mouth, tongue, gums, and pharynx; 
abdominal organs ; contents of stomach, fasces. 

Examination of respiratory apparatus: Nose, mouth, and larynx. The lungs : 
inspection, palpation, percussion, auscultation, mensuration. Cough and expec- 
toration. 

Examination of circulatory apparatus : Inspection and palpation of cardiac 
area; percussion, auscultation of heart; similar examination of arteries and 
veins, the pulse ; examination of the blood. 

Examination of the urinary apparatus: Kidneys, ureters, and bladder; ex- 
amination of urine. 

Examination of the nervous system: Intelligence, subjective nervous phe- 
nomena, sleep, gait, station, reflexes, paralysis, tremor, pain, convulsions, head- 
aches, disturbances of sensation, disturbance of speech. The organs of special 
sense. 

Examination of fluids obtained by puncture. 

Bacteriological examination of blood, sputum, secretions, exudations, etc. 
Diagnosis. 



Treatment. 



Scope of the Work. In the following pages the data collected by 
inquiry and observation will be considered, and the attempt made to 
show their application in individual disease. Hence, the value in diag- 
nosis of the social history, family history, previous disease, and history of 
the present disease, will be discussed. The subjective and the objective 
symptoms of disease and the methods of ascertaining them respectively 
will then be considered. After the subject-matter above indicated is 
considered, in a general way the phenomena or symptoms of morbid 



GENERAL OBSERVATIONS. 



23 



processes or of varying causal agencies will be treated of, in order that 
the student may have a general comprehension of semeiology. 

Classification. This is based upon diagnostic convenience. No 
attempt is made at a scientific pathological classification. Diseases that 
are not common are described under the objective symptoms of disease 
in the order of their chief diagnostic condition — as myxoedema or acro- 
megaly under enlargement — or under the structure or organs the subject 
of objective examination, as myositis under muscles, Raynaud's disease 
under an account of the extremities. 

The student can by ready reference make practical use of the work, 
as the handbook is used in the laboratory, if he will bear in mind its 
plan. He first obtains data by inquiry, reference to which can be made 
under the appropriate section. Subjective phenomena are included in 
the inquiry. After the subjective symptoms are ascertained, the objec- 
tive symptoms are looked for. They are arranged in a manner similar 
to that of the subjective symptoms. Thus, loss of weight will be studied 
in the consideration cf general objective symptoms, contraction of the 
chest under diseases of the respiratory apparatus. An account of gen- 
eral phenomena, or those which refer to a structure of the surface, as the 
skin, the eye, or to general structures, as bone, connective tissue, glands, 
muscle, etc., can be found by reference to the body in general, or to 
each individual structure, arranged under the objective symptoms. The 
phenomena which point to an apparatus or system, as pain referred to 
the chest, for instance, or shortness of breath, will be discussed under 
the chapters which consider the various systems, as the respiratory or 
cardiac system on the one hand, or the digestive on the other. It is 
scarcely necessary to advise the student to consult the index freely. 

There is nothing more important to the student than to have a com- 
prehensive view of any subject under consideration. It is recommended 
that an outline be made of the subject-matter contained in this volume. 
It can be done in small compass, and if carried in the pocket will be 
convenient for review at odd times. It is preferable that the student 
should make the outline himself, hence it is not included in the work. 
He is recommended to note the subjects as arranged in the index as 
headings, and underneath them to jot down the divisions of the subject 
as indicated in the respective portions of the text by the sub-heads, or 
by antique or italicized words. 



CHAPTER II. 



THE DATA OBTAINED BY INQUIRY. 

The Social History : Age, sex, occupation, habits, residence (past and present \ family 
relations, exposure to contagion. The Family History : Parents, grandparents, 
brothers and sisters of each — Brothers and sisters of patient — Wife and chil- 
dren. Previous Diseases. History of the Present Disease : Duration and mode 
of onset — Evolution of the disease. The Subjective Symptoms : Their value — 
Their fallacy — Feigned disease — General subjective symptoms — Local — Pain. 

The subjective symptoms of the disease are elicited first, so that, 
by attending to the complaints of the patient measures may be directed 
promply for his relief ; second, that we may have the advantage of ob- 
servation of the patient's intelligence, expression, etc., aud at the same 
time ascertain the direction further inquiry should take ; third, in order 
that embarrassments may pass off and composure ensue before an objec- 
tive examination is made. It seems preferable, however, to begin the 
record with the social history of the case, for a scientific and orderly pro- 
cession in the data acquired, and then proceed to record the facts of family 
history, previous history, and history of present disease. Certainly it is 
immaterial how they are considered in the following discussion, and for 
convenience, therefore, the above order will be followed. It is to be 
remembered that the patient's complaints, and the objective phenomena — 
or if unconscious or otherwise unable to speak intelligently, the latter 
alone — are the central threads around which the diagnosis is woven. 

The Social History. 

The aid derived in the diagnosis by the collection of data, by inquiry 
into the social history, cannot be considered exhaustively. Works on 
hygiene must be consulted. General ideas will be given; reference to the 
influence of the various factors will be found under the individual dis- 
eases. That such data are of value is seen for instance in distinguishing 
various forms of colic. Knowledge that the patient labored in lead 
often will simplify an obscure problem. 

The Age is learned, for each period in the evolution and involution 
of life has its peculiar physiological processes susceptible to variations 
from external influences. In infancy and childhood the environment is 
inquired into; at puberty again there is change; in middle life the 
influences of occupations or habits are felt; at the menopause the 
blotting out of one function is perturbing; as old age approaches the 
effects of wear and tear and degeneration and cell-wanderings ensue. 

But first, a large group of affections arise in the first period of infancy, 



THE DATA OBTAINED BY INQUIRY. 



25 



from inheritance or congenital malformations, from accidents incident 
to childbearing, and from improper management of the cord. 

Second, in acquiring adaptability to environment, by the feebly resist- 
ing organism, disturbances of digestion from poorly prepared or improper 
food arise; pulmonary disorders from improper clothing, ventilation, etc., 
occur. The developing nervous system has more acute susceptibilities, 
and hence a long array of reflex symptoms or diseases is observed at 
this period. 

Another group of diseases, the exanthemata, and all contagious dis- 
eases, are more prevalent in early life, because they arise out of exposure 
to a specific cause which occurs before the child attains many years. 
The anatomical arrangement of the larynx, disproportionately small, 
makes the diseases of it most frequent in childhood, and a serious 
factor in mortality. At puberty we see the perversions (from earlier 
years) liable to arise as adolescence advances. Anaemia and chlorosis 
are very liable to develop at this period. In the middle period, the 
diseases that arise from occupation, from exposure to external agencies, 
from habits, are seen. Moreover, processes beginning in adolescence 
are reaching their acme, and find expression in later life, as the cysts of 
hydatid disease, or renal calculi, or manifestations of gout. In later life 
the degeneration of the vascular and cerebro-spinal systems occurs; 
cancer, affections due to fibrosis, a resultant of wear aud tear ; calculous 
disease, and other diseases, prevail. 

The Sex. The prevalence of various diseases in the sexes in undue 
proportion arises because of difference in the anatomical structure and 
physiological offices of the two, and because of the difference in ex- 
posure to varying causal agencies. Diseases of the male sex occur from 
exposure, by virtue of their occupation, to causes from which the female 
is exempt, from over-activity of mind and body, and the formation of 
bad habits. The diseases of the female sex that are more prevalent, apart 
from their own peculiar affections arising out of menstruation and child- 
bearing, take place because of the more or less sedentary nature of their 
lives, and hence, among other things, the opportunities for introspection. 
Hysteria and neurasthenia and nerve disorders abound with them. 
Males are more subject to epilepsy, gout, diabetes, locomotor ataxy, and 
vesical disease. Females are more subject to exophthalmic goitre, rheu- 
matoid arthritis, chorea, and the above-mentioned nervous disorders. 

Occupation. This must be ascertained in the inquiry, for each occu- 
pation demands effort in one particular direction, or compels exposure to 
deleterious consequences. Writer's cramp, eye-strain, and a series of dis- 
orders thus arise. Knowledge of exposure to particular irritants, coal or 
fine particles of metal or stone, gases, chemicals, effluvia of all kinds, and 
to diseases contracted from auimals, are valuable points in diagnosis. 

The manner and degree of employment of the mind must be inquired 
into. 

It is not to be forgotten that the occupation at different periods of life 
must be found out, the age at which life's battle began, and the circum- 
stances that surrounded the early career. The deleterious influence of 



26 



GENERAL DIAGNOSIS. 



a former occupation may be observed after the patient is in another 
sphere of labor. 

Habits. Habits as to clothing (catarrhal affections and rheuma- 
tism^ as to hours of rest and sleep (neurasthenia), as to character of 
food, time, regularity, and manner of eating (the indigestions, gout), 
as to the use of stimulants (cirrhosis of the liver, neuritis, brain affec- 
tions), of tobacco (amblyopia, cardiac palpitation), of tea or coffee, of 
narcotics, and as to exercise, must be inquired into. Robbing hours that 
should be devoted to rest, for labor or dissipation, tells a thrilling story 
at times ; it has an influence on the organism for evil. A knowledge 
of the habits, of the life — of the inner life, indeed — of the individual, is 
essential to attain a rational diagnosis, and hence a true therapeusis. 

Place of Residence and Dwelling. A knowledge of the place of 
residence is of service. Town residence or country residence, a resi- 
dence in a damp locality, by the sea or in the mountains, in particular 
valleys, in different watersheds, in tropical or frigid clime, makes an 
impress on the constitution, even if actual disease is not created. Hence 
malarial regions, goitre districts, localities in which vesical calculi are 
prevalent, or in which special epidemic diseases abound, as yellow fever, 
cholera, or dysentery, must be inquired for. Knowledge of the resi- 
dence at different periods of life and the duration of such, is often 
important information. 

The situation, and degree of comfort for habitation, of the dwelling 
must be learned. The sanitary arrangements, drainage, ventilation, 
water-supply, heating, are to be scrutinized. 

Family Relations. Marriage, and the number of children, with 
their degree of health, must be recorded. If a woman, the number of 
children born, the character of the labor, the number of miscarriages. 

Is there trouble in the marital relation ? Has there been sorrow or 
sudden shock, or long nursing, or great care ? Are the financial cir- 
cumstances easy? Has there been recent malfeasance? How many 
invalid women arise out of such ashes ! 

Questions so personal can often only be put after long acquaintance, 
or through judicious inquiry of friends. 

More delicate questions must be put frequently, as to masturbation 
or excessive venery, but with great caution, and only when conditions 
demand it. In epileptiform convulsions, profound hysteria, neuras- 
thenia, the development of locomotor ataxy, or spinal paralysis, prompt, 
clear, manly questions as to these habits are to be put, not reference 
made to them in prudish or mawkish suggestion. 

Exposure to Contagion. If the suspected ailment partakes of the 
nature of a contagious disease, the probability of exposure to the dis- 
ease must be looked into, and the presence of epidemics ascertained. 
The period of incubation must be known in such cases. The prodromal 
symptoms must be ascertained. 



THE DATA OBTAINED BY INQUIRY. 



27 



The Family History. 

The inquiry is instituted in order to determine the affections which 
may or may not be hereditary. We learn also the average duration of 
life in the family, and the relation of the mortality to the physiological 
epochs in life. Data of the latter character is of value in the estimation 
of the possible duration of life for purposes of life insurance, but also 
throws light on the recognition of abnormal conditions ; thus to learn 
that most of the members of the family died of apoplexy at a compara- 
tive early age, or of aneurism or other arterial degenerations, is to learn 
that arterial changes developed earlier than usual. To secure accurate 
data, the age and state of health, if living, of parents, brothers, and sis- 
ters are ascertained ; or if dead, the cause of death and age at which it 
took place. Similar questions may be applied to several generations of 
the family and to collateral branches. 

Concerning the question of direct inheritance of disease, but few are 
strictly so. Of these, nervous diseases are the most common, as pro- 
gressive muscular atrophy, hereditary chorea, Thomsen's disease, Fried- 
reich's ataxia, migraine, epilepsy, and forms of insanity. The writer has 
seen chronic Bright's disease, or a state of the constitution that predis- 
poses to it, occur in several generations without the usual exciting 
causes of that affection. Syphilis is inherited. Haemophilia is the most 
striking affection that is transmitted by inheritance. It is not diseases 
that are hereditary, but types of tissue that predispose to disease, as in 
tuberculosis, or cancer, or conditions of the organism that favor imper- 
fect metabolism, as is seen in gout or rheumatism. 

The family physician, who comes in contact with one or more genera- 
tions, profits most by the knowledge of the family history. He learns 
the predisposition to various minor ailments — to headaches and attacks 
of indigestion, " bilious attacks," for instance; he learns the power of 
resistance in the family to disease, or its capability to undertake large 
duties in life ; he learns of their susceptibility to drugs, and the tendency 
in them to take stimulants. Nerve force is the capital with which the 
battle of life is kept up. If it is at a minimum in groups of families, 
diseases or conditions of poor health due to its use, a use not excessive 
in others, arise. 

In the inquiry, it may be well to ascertain the probability of disease 
being transmitted from husband to wife, or the opposite. Syphilis and 
gonorrhoea, and tuberculosis are examples. Then, too, we must inquire 
of mothers for the manifestations of syphilis in the children. 

Caution must be exercised in the pursuit of knowledge of this kind, 
as strained, or even ruptured, marital relations may result from injudi- 
cious intimations. Not only does it apply to the transmission of disease 
between husband and wife, but its transmission along lines of families. 
Caution must be employed in order not to arouse family pride if evidence 
of " scrofula" is sought for, or provoke undue alarm when inquiry into 
the family history of cancer is made. Inquire for the symptoms of the 
disease in various organs in which it may occur, as jaundice, uterine 
hemorrhage, etc., or ask about growths or tumors. Do not use the 
specific terms, consumption or cancer. 



28 



GENERAL DIAGNOSIS. 



Moreover, care must be exercised to secure definite data, not to lay 
stress upon statements of the patient or parent as to the cause of 
death being "dropsy," or "jaundice," or "cold," or "teething," or 
"change of life." Control questions must be put by inquiry into the 
character of the symptoms that attended the fatal illness, and by giving 
the affections the various popular names that are given them in different 
countries. 

The data of the family history are of no avail unless it is remembered 
that many fundamental affections have various modes of expression. 
Various diseases may be allied to the one suspected to exist in the 
patient, because of this difference of expression. One member of a 
family may die of heart disease, another of rheumatism, or some have 
had chorea, or cutaneous affections, or renal calculi ; such ailments are 
expressions of the same morbid process. Finlayson well puts them into 
groups and fittingly portrays them as follows: "In regard to scrofulous 
[tuberculous] diseases, we ask for swollen glands or 6 waxen kernels/ 
or runnings in the neck, diseases of the spine and other bones, bad 
joints, white swellings, or 'incomes' as they are termed in Scotland; 
disease of the glands, of the bowels, water in the head, consumption of 
the lungs, or decline, or weakness of the chest with spitting of blood, 
and so on. 

"Heart disease, rheumatism, chorea, psoriasis, and some other cutane- 
ous affections, and perhaps renal concretions and emphysematous bron- 
chitis, appear to replace each other in different members of the same 
family. 

"The neurotic group includes the various forms of neuralgia, epi- 
lepsy, hypochondriasis, hysteria, and insanity; apoplexy and hemiplegia 
may (perhaps doubtfully) be included in this group ; their hereditary 
character seems rather to be associated with vascular disorders. Gout, 
disease of the liver, contracted kidney, renal calculus and gravel, and 
angina pectoris form another allied group; and these have also some 
affinity with the disorders connected with arterial degenerations. Syph- 
ilis, which, of course, has marked hereditary characters, assumes such a 
multitude of forms as to preclude enumeration ; but the tendency is for 
such syphilitic diseases to fail in the course of time from early death or 
sterility. Abortions, stillbirths, early deaths in infancy associated with 
cutaneous eruptions on the buttocks, and with snuffles, are important in 
many family histories ; nervous deafness, opacities of the cornea, notched 
teeth, epilepsy, and imbecility are occasional manifestations of the same 
disorder in those children who survive." 

It is thus seen in securing the family history data are acquired which 
may be (1) complete and of value in estimating family tendencies ; or 
(2) vague and of doubtful value. The latter occurs because of the want 
of recollection of matters inquired into, or because of ignorance of the 
terms employed. The difficulties must be overcome by control questions 
prompted by our knowledge of the nature of disease and its frequency 
at different ages, by an inquiry for symptoms, and by investigation into 
collateral and remote branches of the family. 

The fact that diseases skip a generation (atavism) must be remem- 
bered. A generation may be small or decimated by accident or acci- 



THE DATA OBTAINED BY INQUIRY. 



29 



dental disease, and hence the force of the family history be weakened. 
At times in a family, sufficient time had not elapsed for predisposition 
to arise, as when the illness of a child is inquired into, the parents of 
which are in early adult life. Finally, all negative facts must be 
recorded. Such knowledge must act as a control element in the esti- 
mation of the value of the family history. 

Previous Disease. 

The remote effects of disease, and of its sequela?, as impressed on the 
organism, make it essential to inquire into the nature of the previous 
disease of the patient whom we are studying. The date and character 
of the disease, the duration, the degree of severity, and the complete- 
ness of convalescence must be determined. 

Many diseases, as the exanthemata, usually occur but once in the 
same person, and, therefore, in the diagnosis of obscure cases, if a his- 
tory of their occurrence has been ascertained, they can be excluded in 
the count. Others recur from time to time, as croupous pneumonia, 
chorea, acute rheumatism, and tonsillitis. The history of a previous 
attack of a certain disease may point to the nature of a second attack 
which otherwise may be obscure. Some diseases, as rheumatism, syph- 
ilis, and gonorrhoea, have pronounced sequela?. Knowledge of the 
occurrence of the primary disease may solve doubts as to the nature of 
the sequela?. 

Infectious diseases lead to forms of neuritis and to brain affections, 
or to inflammations of organs. The seat of the specific inflammatory 
process varies in different diseases ; after measles we find the mucous 
membranes impressionable ; after scarlet fever, the ears and kidneys 
liable to inflammation. The history of an attack of hepatic or renal 
colic may point to the diagnosis of an otherwise obscure process in the 
respective region. 

The history of injury must be sought for in brain and spinal affec- 
tions. The occurrence of a surgical operation in the past may point to 
lesions for which it was resorted to, which again may be the source of 
disease. 

The History of the Present Disease. 

Scope of the Inquiry. The history of the present disease includes 
an account of the sufferings of the patient, which I have said are the 
subjective symptoms of the disease, and of the duration of the disease, 
of its mode of onset, and the evolution of its symptoms up to the time 
it was seen by the physician. The patient also gives an account of such 
objective symptoms as could be noted by him, as swollen legs, the date 
of their commencement, mode of onset, and progress. In the case 
record, the history to the date of examination is first recorded, and then 
the subjective symptoms are noted. The same order will be followed in 
the text. Practically, it is better to learn the symptoms on account of 
which the patient applied for treatment, and, with that as a guide, to 
inquire into the date of origin and mode of development of the disease. 



30 



GENERAL DIAGNOSIS. 



Method of Inquiry. The history and subjective symptoms are best 
learned in the language of the patient. If the memory fails or the 
symptoms are not clearly narrated, judicious questions will suffice to 
complete the story. Leading questions must not be put until the 
patient's account is fully given. 

Often the patient will be too voluble and introduce irrelevant matter, 
or too taciturn from modesty or a desire to conceal facts, as when ille- 
gitimately pregnant. While much time is lost in listening to a prolix 
or interminable account of sufferings, the student will do well at first 
to bear with the patient, for it gives him the opportunity to study char- 
acter, observe the mental and emotional characteristics of the patient 
and the expression of the countenance. To suppress the loquacious, free 
the tongue of the silent, gather scintillations of intelligence out of the 
dense clouds of ignorance, requires knowledge of human nature of a 
high degree, acquired only by long practice. (Allied difficulties have 
been discussed in the paragraphs devoted to the family history.) Indeed, 
the wonderful faculty of seeking information in this manner is the 
capital of many physicians, past and present, of large practice. It is 
by this means and by tricks that the charlatan plies his vocation. A 
favorite method of the quack, after a few words from the patient, is to 
tell him how he — the patient — feels. They have some knowledge of 
the march of disease, and portray its full development to the surprised 
and credulous victim. Elsewhere (see Subjective Symptoms) the re- 
liability of such data is discussed, and the student must not for one 
moment consider the data obtained by inquiry as of equal value to 
that derived by observation. The one represents the mere skeleton of 
the diagnosis. 

It is particularly important to secure the chronological order of events 
of the disease. It is essential and logical, and holds up to clear light the 
progress of the affection. If such sequence is followed the diagnosis is 
much easier. Of course, there are circumstances when only the mini- 
mum amount, if any at all, of information of this character can be 
secured. The patient may be unconscious, or in a convulsion, or unable 
to speak from dyspnoea. It is necessary then to rely on the testimony 
of friends or to gather it from the circumstances that surround the 
patient. 

Mode of Onset and Duration of the Disease. It is well to 
learn if the onset of the disease was sudden or gradual. If the former, 
the most striking phenomena are ascertained — a chill, convulsion, sud- 
den pain, sudden vomiting, a profuse diarrhoea ; each points to lines of 
further inquiry. If the latter, did it follow upon an acute illness, or 
did each symptom gradually increase in intensity, and as each week or 
each month passed by, new phenomena creep into the symptom-complex. 
We thus learn if the affection under consideration is acute or chronic — 
its duration. It must not be forgotten that certain affections may be two 
or three days, or, on the other hand, as many weeks in developing, as 
typhoid fever, which, nevertheless, is acute. It must be remembered 
also that diseases may have sudden acute expressions, and that a chronic 
disease may be in existence a long time without the knowledge of the 



THE DATA OBTAINED BY INQUIRY. 



31 



patient. An acute colliquative diarrhoea or a convulsion is often the 
first intimation of a chronic nephritis ; an attack of angina pectoris, 
the first symptom of organic heart disease of long standing. To appre • 
ciate the relationship of acute to chronic disease, or of acute phenomena 
to chronic morbid processes, requires a full knowledge of the processes 
of disease. 

Evolution of the Disease. In making inquiry concerning the evo- 
lution of the subjective symptoms complained of, the frequency, dura- 
tion, character, degree of severity, relation of each symptom to the 
function of the organ apparently affected, must be inquired into. Thus 
in the case of pain in the abdomen, we must learn its character, its 
frequency, its duration, its degree, and its location, and whether asso- 
ciated with functional disturbance of any of the viscera in which the 
pain presumably has its origin. Or, if there is frequency of micturi- 
tion, the length of time the symptom was present, the degree of fre- 
quency, the time in the twenty-four hours when the micturition is most 
frequent; its relations to food, exercise, or emotions; the character of the 
act of micturition, and its association with other evidences of functional 
disorder in the genito-urinary tract, or of organic changes in the urinary 
apparatus. 

Having ascertained the full story of the patient, including all data 
obtained by inquiry, special attention must be paid to the sufferings or 
complaints of the moment. In the manner above indicated they must 
be further inquired into. It may be they were detailed in the begin- 
ning ; but information derived by an account of the evolution of the 
disease or the previous history will require a repetition, with the putting 
of fresh questions or control questions. Having obtained the chrono- 
logical account of the factors of life and of disease we are prepared to 
examine into the significance of subjective symptoms. 

The Subjective Symptoms. 

The subjective symptoms are expressive of the sensations of the 
patient, and vary in accordance with the sensibilities of the individual 
affected. Thus acute pain may apparently represent a severe process in 
one, while in another the same severity of process may be represented 
by the minimum amount of pain. It is well known that individuals 
of one nationality bear pain with greater fortitude than individuals of 
another. 

So, individuals vary not only as to pain sense, but as to other subjec- 
tive symptoms. The morale is shattered in some more readily than in 
others ; thus, for instance, oppression of the prsecordia may strike terror 
and be an alarming sign to some, while to others it would be simply a 
sense of discomfort. Moreover, subjective symptoms are constantly 
before the patient, if only in the mind's eye, while in distress, and, 
because of his perturbed state, grow in magnitude rather than lessen. 
We must study them from many points of view. The mode of onset, 
frequency, degree, and character of the symptoms must be inquired 
into. The competency of the witness under the circumstances, from 



32 



GENERAL DIAGNOSIS. 



lack of accurate noting of symptoms, failure of memory, varying degree 
of susceptibility to impressions, etc., may well be doubted. But not 
only does the varying " personal equation " of the patient render sub- 
jective symptoms fallacious ; the same factor in the physician contributes 
to the fallacy. The latter may have unfortunately formed by previous 
hearsay regarding the patient a preconceived notion of the nature of 
the disease ; or from personal bias in favor of particular diseases, on 
account of narrow lines of study or lack of breadth of view of patho- 
logical processes, he sets out to prove a theory rather than establish a 
fact. In either case, by leading questions, by placing emphasis on cer- 
tain parts of the testimony, the subjective symptoms can be juggled 
with and made to tell any but the truthful story. 

It is to be remembered that it is not only our province to ascertain 
the cause of suffering in the sick, but also to detect the flaws in the 
testimony of him who would feign sickness. The malingerer utilizes 
subjective symptoms, because they cannot be seen, felt, weighed, meas- 
ured, or ascertained by hearing, to hide his deception. 

Feigned Disease. To detect feigned sickness implies much acumen 
on the part of the physician. He must not only be able to make an 
accurate and exhaustive objective examination of the patient, but be 
alert to appreciate surroundings and conditions. Feigning may be 
suspected if there is a motive, as in the case of prisoners, pension appli- 
cants, students at school or college, persons who hold policies of insur- 
ance indemnifying in case of sickness. If sickness recurs frequently 
without definite cause, the subjective symptoms of which are mild and 
quickly recovered from, and in which the objective symptoms are nega- 
tive, it should be looked upon with suspicion. The hospital " beat " 
thus plays upon charity. The use of instruments of precision will 
detect the malingerer. By them it can be found out generally if the 
subjective and objective phenomena tally. The absence of such tally 
proves the deception. The thermometer frequently exposes the decep- 
tion, as fever can rarely be simulated, although tricks with the ther- 
mometer may be carried on. A favorite method is to rub it, and thus 
cause the mercury to rise. Frequently the suspected person must be 
placed under close surveillance, unknown to him, and tricks of all sorts, 
suggested by the surroundings and circumstances, played upon him to 
make him unwittingly testify to his deception. 

The student will learn later that there is a mimicry of disease, and 
that in certain nervous affections the simulation of subjective symptoms 
is its chief role. In hysteria, subjective and objective symptoms are 
marked. Long experience and acumen are acquired by the physician 
to unmask the deceptions. The age of the patient, the sex, the state of 
the emotions, the varying expressions of the symptoms (under varying 
circumstances) with attention fixed or removed, the mobility of the 
symptoms under excitemeut or emotional disturbance, the lack of har- 
mony of functional disorder and organic change, are elements to be 
considered in order to fathom the mysteries. Often anaesthesia must be 
induced in order to dissipate simulated tumors, relax rigid joiuts or 
contracted limbs. Magnetism, electricity, and other tests are likewise 



THE DATA OBTAINED BY INQUIRY. 



33 



employed. In the chapter on Hysteria its manifold expressions will be 
adverted to, and it will be seen that functional disorder of almost every 
organ or special sense is simulated in this affection. Organic processes 
even are imitated, as joint inflammations, peritonitis, etc. 

Notwithstanding the fallacy of subjective symptoms in that they may 
be feigned or mimicked, they are valuable evidence at the hands of the 
scientific inquirer. If the patient is a good witness their value is much 
enhanced. He must be intelligent and truthful. His testimony is of 
value if he can array in logical order the sequence of symptomatic 
events which culminated in the condition for which he seeks relief. If 
he can clearly narrate the events in his past life, or in the lives of his 
ancestors, which appertain to physiological aberrations, his story is an 
aid to the searcher for truth. 

If, with this, the doctor is possessed of a scientific turn of mind, 
considering evidence without allowing previous conceptions to influence 
him, capable of discerning the truth and discarding the false, of 
analyzing and weighing statements, aud of appreciating their relation- 
ship to that which is known of morbid processes, the patient's state- 
ments of subjective symptoms are of value in the discernment of disease. 

The Nature of the Subjective Symptoms. The symptoms of 
which the patient complains may be general or local. The former will 
be briefly considered in this section ; the latter will be discussed in the 
respective sections devoted to disease of the various organs to which the 
subjective symptoms refer. They are symptoms due to functional dis- 
turbances of the respective system that is the seat of disease, as dyspnoea 
or cough in diseases of the respiratory system, anorexia or nausea in 
diseases of the digestive system. An exception will be made in the case 
of pain. While there may be such general suffering as to constitute 
pain (general soreness, aching, rhachialgia), yet the symptom has its point 
of origin most frequently in some local disorder. Notwithstanding this 
fact, however, as it is a symptom common to so many affections, and as 
general rules apply to the recognition of its multitudinous forms, a brief 
section will be devoted to its study. 

General Subjective Symptoms. The general subjective symp- 
toms, that is, the normal and disagreeable sensations which extend 
more or less over the whole body, or are referable to more than one 
organ or apparatus, are few in number and are not diagnostic of any 
particular affection. They are at times the only symptoms complained 
of by the patient, and require investigation, in order to give relief. 
They include abnormal sensations of strength or weakness, general 
numbness or tingling, and general paresthesia of all kinds; general 
vasomotor disturbance, causing sensations of heat, as occur in flashes, or 
sensations of cold, from mild chilliness or " creeps " to the pronounced 
chill or rigor, sudden perspirations, general throbbings or pulsations, 
and general discomfort, to which the term nervousness is applied. Irri- 
tability, disorders of sleep, and the more distinct nervous manifestations 
above mentioned will be referred to in the sections on nervous disease, 
and particularly discussed uuder Hysteria and Neurasthenia. 

3 



34 



GENERAL DIAGNOSIS. 



A feeling of strength, or the idea of an ability to perform great feats 
of strength or endurance, or a great mental feat, is a subjective symptom 
that is dwelt upon by the patient who is about developing or passing 
through certain stages of paretic dementia. It is accompanied by other 
evidences of exhilaration. Exhilaration attends chlorosis and forms of 
hysteria and neurasthenia, the physical or mental exhibition of strength 
taking place in the after part of the day and evening, or upon undue 
excitement. Corresponding depression usually follows. 

A sense of weakness, or exhaustion, or of fatigue is often complained of. 
If an absolute demand is made upon the body strength it can respond, 
but otherwise it is not exerted. The patient complains of being more 
tired in the morning than upon retiring, or of a sense of inability to per- 
form accustomed or special duties. Mental depression usually attends 
the phenomenon. It is due to neurasthenia generally, but is a frequent 
accompaniment of and dependent upon the forms of toxaemia to which 
malaria, gout and rheumatism belong ; of the toxaemia of certain varieties 
of indigestion, of tobacco, alcohol, and other narcotic poisons (tea or 
coffee) and of mineral poisons. The same sense of fatigue attends the 
prodromal stage of the specific fevers. It has been a symptom observed 
frequently of late in the sequential period of influenza. 

The sensation of weakness must not be confounded with true weak- 
ness or muscular prostration. While the patient is aware of its presence, 
it is well to consider it under the objective phenomena of disease, for it 
is a readily recognized sign of disease. 

Numbness, or tingling, or burnings may be general or local. It is a 
common form of paresthesia, to be discussed in the section on nervous 
diseases. It must be remembered that, while a disorder of sensation, it 
is due to morbid conditions outside of the pale of the nervous system. 
It may be of reflex origin, from irritation at a distant point, or it may 
be and usually is due to a toxaemia, as lithaemia. Other subjective 
vasomotor disturbances that are of frequent occurrence are likewise 
manifestations of nerve disorder from reflex or toxic causes. Flushings, 
or a constant sensation of heat with or without perspiration, which attend 
the perturbation of the menopause, are common in uterine disorders and 
in chronic gastritis. 

The student will learn that the curious manifestations to which refer- 
ence has been made are generally all evidences of ill health, of a 
depressed vitality, of a condition in which there is malnutrition, poverty 
of nerve force, and lack of blood richness (anaemia). There may be 
peripheral irritation or a toxaemia, but the under-current of ill health is 
the fundamental derangement. 

Chill and /ever. Both are subjective as well as objective phenomena, 
but as one can be accurately estimated by an instrument of precision 
(thermometer), and as both are generally associated, the discussion of 
them will be postponed. (See Objective Signs.) 

The abnormal sensation of cold or of heat will be discussed in the 
chapter on Nervous Diseases. 



THE DATA OBTAINED BY INQUIRY. 



35 



Pain. 1 

Definition. Pain is a general term used in medicine to describe a 
number of subjective symptoms connected with morbid processes. It 
may be denned as the expression in consciousness of injury to the periph- 
eral nervous system, provided the injured part is in connection with 
the seat of consciousness, the brain (Payne), or it may, in general, be 
defined as sensation received by the perceptive centres from the afferent 
conducting paths, which sensation produces on the part of the organism, 
as a whole, the desire to abolish or escape from it. This definition, 
however, fails to include the hyperesthesias, the hyperalgesias and all 
simulated pains. But the latter are to be included in this section, on the 
ground of clinical convenience ; whilst the two former are only of sig- 
nificance as conducing to the causation of pain. 

Pathology. The pathology of pain is generally believed to be a 
state of impaired nutrition, and hence of injury, gross or microscopic, of 
some portion of the afferent nerve tract. The cause may be purely func- 
tional, as, for example, when pain is due to the over-stimulation of the 
tract by its normal stimulus, and its consequent exhaustion ; or to 
strictly local conditions, as pressure, injury, or inflammation ; or to 
systemic conditions acting locally, as the neuralgias of anaemia. There 
is also the so-called sympathetic or reflex pain, due to irritation in a 
part removed from the locality to which the sensation is referred. In 
certain cases of neuralgia the nature of the disturbance has not been 
ascertained. 

Variations in Disease. Pain is, perhaps, the most variable symp- 
tom in disease. It ranges from a sensation of mere discomfort, as the 
dull ache of chronic lumbago, to the stabbing pain of pleurisy or the 
intolerable anguish of heart-pang. It is at times compatible with the 
highest mental endeavor or the severest physical exertion, or it absorbs 
the whole energy of the organism in resisting it. It may be definitely 
localized in any part of the body, in any of the tissues, or distributed 
over an ill-defined area. 

The Recognition of Pain. ^The Mode of Expression. Asa rule, 
the physician learns of its existence by communication from the patient. 
Thus he learns more or less accurately its location, character, degree, and 
duration ; and usually something concerning its causation. But the 
value of this source of information is variable. The patient may be 
voluble and describe too much ; or taciturn and admit too little ; or 
ignorant and unable to give a clear account. Fortunately, there are 
other ways by which suffering is expressed, (a) Facial expression, the 
most common interpreter of the emotion, is far more reliable. The 
tense and drawn lineaments, the clinched jaws, the dilated pupils, the 
livid countenance, the labored respiration, the general shrinkage of the 
body, make an unmistakable picture of agony, Or, in a less intense 
form, the shrieks and struggles or the groaning of more prolonged 
suffering are no less impressive in their suggestiveness. (6) Not less 

1 Pain is treated of in a suggestive manner and so much space given to it because it is too fre- 
quently improperly managed. Its cause is never thoroughly investigated. Anodynes are given 
for its relief, thus too frequently creating victims of the morphine, chloral or other vicious habits. 



36 



GENERAL DIAGNOSIS. 



characteristic are the various postures assumed • the sudden fixity of 
heart-pang ; the retracted head of meningitis ; the immobile side of 
pleurisy ; the crouching attitude of cramp ; the flexed thighs of 
peritonitis ; or the bent knee of arthritis, (c) Further, there are cer- 
tain reflex actions that are associated with local irritations ; thus the 
closure of the eyelid on irritation of the conjunctiva, the sneeze or cough 
on irritation of the nasal or laryngeal mucous membrane, the erection 
following irritation of the urethra, or even the limp characteristic of 
pain on moving or resting the weight of the body on an affected limb. 
Then there is the sudden shrinking of the whole body, the attempt to 
defend, or the sudden movement of the hand to, the affected part, or 
the sudden jerking away of the part itself if the act be possible ; these 
are true reflexes and sufficiently diagnostic of local suffering. It scarcely 
need be mentioned that in children, in the insane, in persons unable for 
many reasons to communicate their thoughts, the expression of pain is of 
the greatest diagnostic value, as to the determination of the seat of pain. 
(d) The associate phenomena of morbid processes may serve to indicate 
the occurrence of pain and its seat. Thus pain is one of the cardinal 
symptoms of inflammation ; it is commonly associated with nerve injury ; 
it is frequently accompanied by local flushing in neuralgia. 

Sources of Error. In estimating the presence or absence of pain, 
or its degree, certain control conditions must be borne in mind. Un- 
fortunately pain is one of the most unreliable of symptoms. It is neces- 
sarily a subjective symptom, with, in all probability, qualitative as well as 
quantitative variations. The particular degree in either respect is of im- 
portance in diagnosis, and as only the roughest means, if any, are avail- 
able to estimate it objectively, the physician is compelled to rely almost 
wholly upon the statements and appearance of the patient. His statement 
can err in two directions ; the patient can exaggerate his sufferings or 
depreciate them. The tendency to exaggeration is most marked in the 
nervous temperament, in those suffering from chronic disease of long 
standing ; in those accustomed to indoor and mental labor ; in women, 
and in the young. The tendency to depreciation is most marked in the 
phlegmatic temperament ; in those accustomed to hardship, especially 
if of small intellectual development ; in men ; and in the aged. Both 
tendencies are to be corrected as nearly as possible by observance of 
the associated symptoms, and the character of the patient, and by skilful 
questioning. The appearance can deceive because of undue suscepti- 
bility to suffering on the part of the patient, or unusual inhibitory 
power. There can be no question that painful stimuli, normally easily 
borne, in some produce almost unbearable misery. Such exaggerated 
sensibility occurs in the emotional, in the weak and debilitated, and in 
the delicately nurtured. Mental association is a powerful factor ; it is 
well known that soldiers, who in the heat of battle disregard serious and 
necessarily painful wounds, will suffer intensely under the probably 
less painful offices of the surgeon ; and unfortunately it is a common 
experience that the surroundings of the operating-room make the most 
trifling and briefest operations full of serious suffering. Habitual use 
of opium seems in a remarkable manner to increase this susceptibility. 
Patients will even submit to operations for the relief of a supposed ail- 



THE DATA OBTAINED BY INQUIRY. 



37 



merit that is found to have no physical basis ; and this occurs in cases 
where there is uo reason to believe that the pain is simulated as an ex- 
cuse for the indulgence. Inhibition is a much more serious source of 
error, for while undue attention to one part is only reprehensible when 
practised to the neglect of others, a patient who disregards pain may 
fail to direct attention to the real seat of disease. It is sometimes ex- 
ercised to a most remarkable degree. The stoicism of the American 
Indian under torture is attested by many observers ; certain religious 
sects among the Hindus habitually afflict themselves in the most inge- 
nious ways ; the early Christian martyrs rejoiced in misery. It is 
common to note this disregard among those exposed by occupation to 
discomfort and injuries, and the Teutonic and Slavic races appear to 
possess it in a higher degree than the Celtic or Semitic. Shock either 
inhibits pain or diminishes the normal response to it. Lastly, and by 
no means to be neglected, a most common source of error is due to 
undue credulity or skepticism on the part of the physician ; for he may 
be deceived by an eloquent and persuasive complaint or discredit true 
suffering. 

Simulated pain (see Feigned Disease) is to be recognized by the pres- 
ence of an object. The simulation is common enough nowadays, in those 
who seek damages for injuries, or in those who have a morbid craving for 
sympathy and attention. The detection of this depends upon the skill 
of the physician, for, with ingenuity, by distracting the attention from 
the part complained of, he observes that the pain disappears, or pain is 
admitted in a part to which attention is directed ; moreover, the phy- 
sician observes an absence of adequate physical alteration, and usually 
inconsistency in the symptoms, for rarely is the malingerer able for any 
considerable time to act a correct clinical picture. Especially in the 
latter case is the observation of the surroundings of the invalid of con- 
siderable importance. The so-called hysterical mask is of much value; 
the bitter complaints and the placid or even smiling features cannot 
fail to strike the observer by its incongruity. True hysteria is apt to 
be deceptive, and more than one humiliating failure is recorded, of even 
the most skilful of our craft. The difficulty is increased because true 
physical changes occur, as amaurosis with dilatation of the pupil, con- 
tracture and induration about the joints, unquestionable anaesthesias 
and palsies. It is often to be detected only after prolonged and pains- 
taking study of the case, the careful exclusion of organic visceral dis- 
ease, the absence of the characteristic symptoms of the nervous degener- 
ations, such as ankle-clonus, or altered electrical reactions, or changes of 
the fundus oculi, and often by the impossibility of associating the sensory 
lesions with the known anatomical distribution of the nerves. 

Objective Investigation of Pain. In order to estimate accurately the 
diagnostic value of pain, the statement of the patient must be corrected by 
his expression, posture, and manner, and the apparent nature of the dis- 
ease. Pain is one of the cardinal symptoms of inflammation ; vasomotor 
and muscular disturbances are often associated with neuralgia ; any morbid 
condition exerting pressure on a nerve trunk, as a neoplasm, callus, etc., 
commonly causes pain. Hence, if the objective phenomena of these dis- 



38 GENERAL DIAGNOSIS. 

orders are present they lend color to the complaint of pain, and, if not 
complained of, they should be inquired for. Attempts have been made 
to introduce scientific accuracy into the estimation of the degree of the 
sensation of pain, or at least to secure a practical method for measuring 
its varying intensity in different localities in the same case. Bjornstrom, 
of Upsala, has contrived a pair of forceps that compress a fold of skin ; 
the amount of pressure required to produce pain, which can be read from 
a scale, indicates the degree of sensibility or rather resistance to painful 
impression. Another instrument, Buch's, accomplishes the same thing 
by direct pressure, and hence can be used over the superficial nerve 
trunks. Another method more generally available is the application of 
an induced current of variable strength ; single, naked-wire electrodes 
being best for this purpose. And the common clinical method, by far the 
most inaccurate and only applicable in considerable degrees of analgesia, 
is a pin or needle forced through a fold of skin. No method has yet 
been suggested for even the approximate estimation of the degree of 
internal pain, and it must still be left to the judgment of the patient. 

The Clinical Value of Pain. The presence of pain is recognized 
by the above-mentioned circumstances. Its degree, with the limitations 
indicated, has been estimated. Its clinical value is then to be considered. 
From what has been said above, the converse of many of the proposi- 
tions is true. By pain and the mode of its expression we can judge 
of the character, temperament, and nervous susceptibility and pertur- 
bability of the patient. It aids us in the recognition of hysteria 
and helps to detect the malingerer. We learn the capability of 
resistance of the patient, and hence in a measure of his strength. We 
learn of the receptivity in consciousness of the peripheral irritation. 
The degree of intelligence, or the amount of stupor, is thus recog- 
nized. Or, if conditions are present which usually cause pain, its 
absence may show disease in the conducting paths to the brain. 
Further, the absence of pain under the above circumstances points to 
the occurrence in the local process of such change as has destroyed 
peripheral nerve-endings. Thus, when pain ceases in dysentery, gan- 
grene has ensued. In intestinal obstruction, its cessation indicates the 
same process. In profound shock, pain is not complained of ; the 
amount of pain, therefore, tells of the degree of shock. Hence, in 
peritonitis, in which shock frequently occurs, pain may be wanting 
entirely. The abdominal surgeons welcome its occurrence after an 
operation. 

While the above lessons, from the presence or absence of pain, are not 
to be underestimated, the value of pain to the physician is from the 
standpoint of diagnosis. 

By this symptom we may be enabled to determine (1) the location of 
disease, and judge (2) of the nature of the morbid process on account 
of which it is excited. The location of the disease is judged (a) by the 
seat of the pain and (6) in part by its character. The characteristics by 
which pain is recognized (see p. 35) also indicate to us its point of 
origin in a general way, and its probable cause. They are (1) the facial 
expression, (2) the position, (3) the reflex actions, (4) the associate phe- 



THE DATA OBTAINED BY INQUIRY. 



39 



nomena. They need not be referred to again. The nature of the morbid 
process is judged by the study of pain from various standpoints. Thus, 
in the case in which pain is complained of we must learn, first, the 
mode of onset ; second, the duration ; third, the time of occurrence ; 
fourth, the character or variety of the pain ; fifth, its seat ; sixth, its 
variability as affected by pressure, temperature, rest, motion, posture, 
electricity, drugs, and climate. 

1. Mode of Onset. The mode of onset of the pain is in the 
majority of cases an indication of the acuteness of the morbid process. 

a. The onset may be sudden. 1. In gout or acute inflammations of 
serous membranes, as pleurisy or peritonitis, pain may occur sud- 
denly. 2. It is sometimes of sudden occurrence in certain headaches, 
particularly of congestive or emotional origin. 3. When pain occurs 
suddenly it is due, further, either to sudden obstruction of parts that 
are sensitive, or to effort on the part of the structure to remove a foreign 
body, as in the intestines, the gall-ducts, the vermiform appendix ; or 
in the respiratory tract, the nares, or the bronchi ; in the geuito-uriuary 
tract, the ureters, bladder, or uterus. 4. Moreover, sudden pain may 
indicate rupture of the structure in which it is developed. Here we 
have the most typical sudden pain. Thus, in rupture of an aneurism 
or of the heart, there is sudden sharp pain. In rupture or perforation 
of the stomach, of the intestines, or auy of the hollow viscera, this 
character of pain arises. 5. Sudden pain also occurs in certain neu- 
ralgias or neurosal affections. It is seen in its most striking form in 
angina pectoris, and in sudden brow-ache, or trigeminal neuralgia. 

b. Pain that develops gradually indicates that the process is one of 
gradual development and not attended by a Solution of continuity," 
as from rupture or tear. It is the pain that usually occurs in various 
forms of rheumatism, in inflammations of muscles, and of mucous mem- 
branes, in slow inflammations of serous structures, and in chronic bone 
disease. 

2. Duration. From the duration of the pain we learn of the 
acuteness or chronicity of the morbid process on account of which it 
is generated, a. Pain of short duration is seen in the affections in 
which it develops suddenly (see Mode of Onset), in acute serous in- 
flammations, and in neuralgias, b. Pain of long duration, if con- 
stant, is usually due to organic lesions; if intermittent it may be 
due to neuralgia. Pain that is continued over a long period of time 
excludes the sudden accidents that were previously mentioned, unless 
change in the character of the pain takes place. Pain is also divided, 
as to duration, into temporary and constant pain. a. Temporary pain 
indicates an abeyance or relief of the morbid process, while the constant 
pain points to its continuance. 6. Constant pains are seen in bone 
affections, in inflammation of muscles, in reflex pains due to chronic 
disease elsewhere, as the backache of uterine disease, or the infra- 
mammary neuralgia from the same cause. Pain may also be inter- 
mittent, remittent, and paroxysmal, or periodic, a. Intermittent and 
remittent pains are characteristic of neuralgias, or point to a functional 
origin, recurring because the cause which superinduces them is again 
operative. Thus headaches due to eye-strain may be intermittent 



40 



GENERAL DIAGNOSIS. 



or remittent in the sense that they only occur when the eye is used. 
Such pain continues over a long period, b. Paroxysmal pain is 
the form which occurs wheu there is obstruction of channels, as the 
gall-ducts in biliary colic ; the intestines, the uterus, and the ureters in 
the various forms of colic to w r hich they are liable. The paroxysms of 
pain recur in the course of the attacks, c. Periodic is applied to pains 
that occur at distinct intervals. Pain that is periodic has frequently 
for its cause malaria in some form. The toxic headaches and nerve 
headaches, as migraine, are often periodic. (Consult Headaches.) Pain 
that attends definite states of exhaustion which occur periodically, as at 
the menstrual period, is of this type. 

3. The Time of Occurrence. On inquiry as to pain and its charac- 
teristics some evidence of diagnostic value is derived by knowledge as 
to the time of occurrence of the pain. Pains may occur only in the day- 
time, or only during the night. Nocturnal pains are common in syphilis. 
They are usually due to periosteal inflammation, and occur after the 
patient is in bed. Pains that are limited to the day are usually reflex 
pains from functional disorder. Some pains, as headache due to cardiac 
weakness, and forms of anaemia, are present during the day, because 
the patient is in the upright position. They disappear in the recumbent 
position, and hence are not present at night. 

The time relation of pain to functional acts is of importance. Thus 
in gastric pain, its relation to the taking of food is ascertained. Pain 
coming on before meals is gastralgic ; occurring after meals, it is due to 
ulcer or cancer, sometimes to indigestion. So we inquire of chest pain, 
is it increased by exertion? 

4. Character. Pain may be sharp, lancinating, stabbing. Pain 
of this character is usually due to inflammation of serous mem- 
branes, to colic in various forms, and to forms of neuralgia ; cutting 
pain is a sharp form that occurs in flatulent colic. Throbbing pain is 
usually associated with acute inflammation, whether superficial or 
deep. It may be rhythmical with the pulsations of the heart. Dull 
pain is due to slow chronic inflammation in the bones and in the vis- 
cera ; it is the pain of myalgia and of fatigue in the muscles. It may 
be of an aching character. But aching pains may also be general ; they 
are found among the prodromata of the acute diseases, attend and follow 
a chill, and occur in most characteristic form in influenza and dengue. 
Pressing pain is complained of when pain attends an attempt to remove 
material from the viscera, as the passage of water when the bladder is 
inflamed ; passage of faeces in dysentery ; the passage of clots or other 
material from the uterus is attended by pain with pressure or bearing- 
down sensations. The term tenesmus is applied to it, so that we have 
vesical tenesmus and rectal tenesmus. 

Finally, the character of pain is often an indication of the nature 
of the disease as well as of the tissue affected : 1. Thus, the bone and 
periosteal pains are boring and constant. 2. In muscular affections 
there is soreness or aching. 3. In the serous membranes the pain is 
sharp and stabbing. 4. In the mucous membranes, dull and burning. 
5. In the skin, burning or itching. 6. In the viscera, dull and usually 
steady, although in malignant disease of the various organs it may be 



THE DATA OBTAINED BY INQUIRY. 



41 



sharp and paroxysmal. 7. Aching, burning, and throbbing in the 
nerve trunk and its distribution, with tenderness, commonly indicate 
neuritis. (See " pain crises," page 43.) 

5. Location. This is, in general, an indication of the location of 
the disease. It may be accepted as an almost universal rule that pain 
due to a local process is limited to the immediate or associated nerve 
supply of the diseased region. This holds true even when the referred 
pains, that is, those felt in the associated nerve supply, are as far distant 
from the site of the morbid process as the knee pain of coxitis, the 
shoulder pain of hepatic disease, or the ear and temporal pain of lingual 
carcinoma. 

It may be of questionable advantage in some cases that the localiza- 
tion of pain generally indicates the situation of the morbid process. 
Too often an explanation of the symptoms, apparently adequate, may 
thus be found, whilst other pathological changes may be overlooked. 
But on the contrary, the condition to which attention has been called by 
the pain might, on account of its obscurity or unusual location, altogether 
escape observation. 

In the first place we determine whether pain is general or local. 
1. General pains are due either to central or peripheral disturbance of 
the nervous system by a poison circulating in the blood. This may 
be the poison of fevers, or may be a rheumatic or gouty poison. It is 
seen in the common affection known as " cold," when the pains are 
probably myalgia In syphilis, malaria, lead-poisoning, and toxaemias 
generally, there is general pain, soreness, and fatigue. General pains 
are not confined to the muscles, but are also seated in the fibrous 
structures and bones. In their more severe forms such pains occur in 
dengue, and are known as " break-bone." 

2. Local pains may be (a) superficial or deep-seated ; (6) they may be 
limited to a small area or radiate in various directions, a. Superficial 
pains are due to involvement of the superficial nerves distributed to the 
skin or to the muscles directly underneath or to the structures in close 
relation to the skin, as the peritoneum, the pleura, or pericardium. Deep- 
seated pains, when in the extremities, are due to bone disease ; when in 
the abdomen, to disease of the viscera, particularly inflammatory affec- 
tions ; when in the chest, to disease of the aorta and mediastinum. The 
diagnostic value of these forms of pain can readily be appreciated. 
Thus, when pain is complained of in the abdomen, if superficial, it is 
due to the nerves and the muscle or to the peritoneum. If deep-seated, 
it may be due to inflammation along the vertebral column, to cancer or 
ulcer of the stomach, to aneurism, to disease of the pancreas, or of the 
liver. In the lower portion of the abdomen it is due to pelvic or renal 
disease. (See Abdomen.) In the same manner, in the chest the super- 
ficial pains are due to affections of the walls of the thorax, or of the 
serous coverings of the lung or heart. The causes of deep pain have 
been mentioned. 

b. The area. In studying the localization of pain we inquire whether 
it is circumscribed, diffused, or radiating. Circumscribed pain is always 
due to a small area of disease, or is reflex. Thus, in ulcer of the stomach 
the pain is usually circumscribed to a small area in the epigastrium ; in 



42 



GENERAL DIAGNOSIS. 



inflammation of the appendix, to the region of that structure. Diffused 
pain indicates involvement of a large area with less intensity of process 
than when circumscribed. Pains that are radiating are usually distrib- 
uted in the area of the nerve distribution related to the point of origin 
of the pain. We learn much from the study of this distribution : the 
pain of cancer of the anterior portion of the tongue may be chiefly 
complained of in the ear ; the pain of disease of the hip, at the knee- 
joint ; of the liver, at the shoulder. The pain of angina radiates down 
the arms ; of renal disease, to the head of the penis or to the testicles. 
In diaphragmatic pleurisy the pain is referred to the front of the abdo- 
men above the umbilicus. Peripheral pains. Radiating pains, however, 
are chiefly due to disease in the course of the nerve, the pain being 
referred to the trunk and terminal distribution of it. In disease of or 
pressure upon the nerves as they go out from the spinal canal, pain 
may not be complained of in these situations, but at the periphery of 
the nerves at the centre of the abdomen. Pain over the abdomen is fre- 
quently an indication of disease of the vertebrae, propagated by the sixth 
or seventh dorsal nerve. Pain between the shoulders is often due to 
aneurism with pressure upon the vertebrse. (See Pain in the Heart.) 

Hilton lays down the rule that pain in any part, in the absence of local 
inflammation, is due to exalted sensitiveness of the nerves of the part, 
and depends upon a cause remote from the painful area. The term sym- 
pathetic is applied to this group of pains. Further, Hilton remarks that 
pain on the surface of the body must be expressed by the nerve which 
resides there, and somewhere in the course of its distribution between 
the peripheral termination and its central origin the cause of the pain 
must be situated. This applies particularly to the pains which arise 
from disease of the vertebrse. To the same class belongs the pain 
on the inner side of the knee in hip disease ; at the extremity of the 
urethra in disease of the bladder ; in the testes and thigh in renal cal- 
culus, and at the tip of the shoulder in affections of the liver. Pain 
in the phrenic nerve, in the neck, may be due to pericarditis or dia- 
phragmatic pleurisy. For the same reason pain over different areas 
of the scalp should be investigated, for often a localized pain is due to 
disease of the fifth nerve somewhere in its course. In a similar 
manner pain in the legs is frequently due to cancer of the rectum or 
bladder. In ulcer of the rectum, pain, cramps in the legs, numbness, 
and even loss of muscular power, are sometimes confined to the left 
side only. The same lesion causes pain in the lumbar region, as well 
as in the limbs. Hilton describes a case in which pain over the sciatic 
nerve, over the left hip and loin, and over the right leg, was due to 
a small ulcer in the anus, the curing of which caused relief from the pain. 
As a corollary to this, in the investigation of the cause of pain, the 
nerve, its connections, and the organs supplied by it, should be investi- 
gated. Bilateral, symmetrical, and superficial pains indicate a central or 
bilateral cause ; while, on the other hand, unilateral pain implies a 
seat of origin which is one-sided. 

Peripheral Pain of Central Origin. In addition to the class of 
cases, which are of peripheral origin, we must refer to the pains in 
the extremities or in the trunk that are due to central disease. In 



THE DATA OBTAINED BY INQUIRY. 



43 



meningitis and other general organic affections of the brain and cord, 
peripheral pains are most common, and they may be the earliest and 
most striking symptoms. Indeed, it is most common to find patients 
with spinal disease to have been treated for a long time for what was 
supposed to be rheumatism. The pains of central origin in the joints 
may be constant, or may arise in paroxysms and be of a lancinating 
character when the disease is chronic. (See Character, page 40.) Severe 
paroxysms of pain may occur under these circumstances and be most 
excruciating, sometimes causing collapse. They are known as pain- 
ful crises. In addition to the joints, pain may be complained of in 
various viscera. Sudden, intense pain, with functional disturbances 
of the affected viscera, occurs independently of any lesion of the part 
or of any apparent exciting cause. One class of the attacks is known 
as gastric crises. The pain is in the epigastrium, and is associated 
with vomiting. In another class laryngeal crises occur with pain in 
the larynx and violent spasmodic cough, with dyspnoea. The pain 
extends over the shoulders. Or we may have rectal crises, with sensa- 
tion of burning in that situation ; urinary crises, simulating renal colic, 
and genital crises. Pain in the muscles, like crises, also occur. Crises 
occur chiefly, if not entirely, in locomotor ataxia. They are distinguished 
from the pain of other causes by their sudden onset, their extreme 
severity, the absence of organic, disease or local cause in the affected 
viscera, the sudden termination, the normal condition between the 
attacks. 

Pain in the joints and in the periphery of the extremities is of fre- 
quent occurrence in neuritis ; inflammation of the sciatic nerve may cause 
pain in the extremity of the foot. Pressure inflammation on that nerve 
may also give rise to distal referred pain. 

6. Pain Modified by Pressure, Movement, Rest. We also 
study pain under the influence of pressure, movement, temperature, rest, 
etc. Pain that is modified by pressure is generally superficial. It is 
usually of an inflammatory origin. The variety of the pressure gives 
some clue to the nature of the pain. If pain is increased by pressure of 
the finger tips it is due to ulcer or inflammation, when internal, and to 
inflammation if external. Gastralgia and colicky pains in the intestine, 
which may be neurotic, are relieved by pressure, particularly if the 
whole hand is applied. Pain that is due to dislocation of some organ, 
as movable kidney or displaced uterus, or to dependent viscera, may 
be relieved by judicious pressure in the proper direction so as to 
relieve the displacement. The pain that arises from affections of the 
nerve trunks can be distinctly localized by pressure in the course of the 
nerve trunk, and particularly at the points where the cutaneous filaments 
of the nerves come through the fascia. These points are along the 
vertebral column, in the axillary region, and anteriorly about the 
parasternal line, in general. By determining the presence of these 
tender points we distinguish neuralgias from myalgias. Pain due to 
bone disease can frequently be distinguished in this wise. By pressure 
or weight upon the head or shoulders we may ascertain whether pain is 
due to vertebral disease. 

Pains increased by movement point to an affection of the bone, 



44 



GENERAL DIAGNOSIS. 



muscle, joints, or Derve in the part moved, as a limb ; groups of mus- 
cles may be isolated for the tests. Some few pains are relieved by 
movement of the body, only because the mind is diverted in this act. 
Pain increased by movement is due to myalgia or rheumatism, when 
superficial. 

Almost all pains are modified by rest. Its influence has but little 
diagnostic significance. In some cases of doubt as to the nature of a 
visceral pain, functional rest of the organ, by which relief is obtained, 
may aid in determining its locality. Thus, rest to the eye may relieve 
a headache, the nature of which was obscure until this respite was 
secured. Pain modified by temperature (heat or cold applied to the 
spine, hot water in a sponge) and by electricity, usually gives infor- 
mation as to the seat of disease in the spinal column, of which the 
pain is the external expression. Pain modified by climate is rheu- 
matic or neuralgic ; modified by weather or season, is due to neuralgia 
or neuritis, whether of gouty or traumatic origin. (See papers by 
Weir Mitchell.) 

Resume. Notwithstanding clinical investigation we may not be able 
from the characters and locality to determine the real cause of the pain. 
In general it may be borne in mind that pains are due to (1) disease of 
the central nervous system or the nerve trunks ; (2) to inflammations ; 

(3) to intoxications, as from malaria, lead and other forms of toxaemia ; 

(4) to pressure on the nerve trunks; (5) to reflex influences. If in 
doubt, therefore, the general symptoms and condition of the patient 
must be ascertained in order to determine the causal origin and hence 
the true nature of the pain. In all cases of pain the controlling motive 
in diagnosis should be to determine the general condition of the patient 
and find the cause of the pain. 

Reference must be made to the curious change that takes place in the 
chronic intoxication of morphine. Persons with the morphine habit 
are very liable to have functional pain. This form of pain usually is 
paroxysmal and severe, and may simulate organic pains. The most 
common clinical form seen is gastralgia. The subjects of locomotor 
ataxia suffer from pain on account of which they have to take enormous 
doses of morphine. This habit is soon acquired, but notwithstanding 
the dose of the drug paroxysmal pain continues. Its severity simulates 
the crises of the primary disease. It becomes a very difficult matter, 
often impossible, to decide whether the pain is due to the morphine habit 
or to the primary affection. 

Pain in Special Reg-ions. (For head pain, see Nervous Diseases ; 
for pain in the thorax and abdomen, see the respective sections.) 

Pain in the Extremities. We have referred to pain in the extrem- 
ities which may be due to disease of the spinal cord, and pain of neu- 
rotic or toxemic origin. When not due to local traumatic, rheumatic 
or gouty inflammations, pain in the extremities, unilateral or bilateral, 
is usually due to neuritis of some form. It is recognized by tenderness 
in the course of the sciatic nerve at its exit from the pelvis, and by 
increase in the pain when the limb is extended by forced movement. 
One of its many branches may be affected, exhibiting tenderness in its 



THE DATA OBTAINED BY INQUIRY. 



45 



course. Such neuritis is usually traumatic (cold), alcoholic, rheumatic, 
gouty, or syphilitic ; the exact cause in each case must be ascertained by 
the associate phenomena and the exclusion of other causes. We may 
distinguish the gouty or rheumatic state on account of which the disease 
depends, by (1) the history of previous attacks of pain or rheumatism 
in other situations ; (2) the family history of rheumatism ; (3) the history 
of exposure which induced the attack; (4) the character of the pains; (5) 
the occurrence of pain or rheumatic manifestations in other tissues, as 
myalgia or pain in the fascia; (6) the occurrence of symptoms of lithsemia 
(which see), and particularly the character of the urine. 

Bilateral pains in the extremities are often of central origin. 

Fixed pains in the extremity, in contradistinction to the mobile pains 
of neuritis, are usually situated in the fascia or muscles, or in the bony 
structure of the part. They may be the result of strain or injury, 
which must be carefully inquired for. The latter may be the exciting 
cause only, if it occurs in a person of rheumatic diathesis, the fixed pain 
at the situation of the injury being due to the general rheumatic state. 
Fixed traumatic pains are usually accompanied with tenderness on 
pressure and are aggravated by movement both active and passive, the 
tenderness on pressure not necessarily being in the nerve trunk. The 
special pains about the foot which we are called upon to treat and which 
have their origin in causes independent of the nerves, or of a rheumatic 
or gouty diathesis, are : 

1. Pain in the articulations due to flat-foot. This may be in the 
tarsus or at the metatarsal articulations. It is a common cause of pain 
in the extremities and may be unilateral or bilateral. The flat-foot 
from breaking of the arch can readily be recognized ; pressure on the 
sole of the foot may increase the pain. 

2. Pain in the heel. This is usually of gouty origin, and is a persis- 
tent source of complaint in many instances. 

3. Pain in the interosseous spaces between distal ends of the third and 
fourth metatarsal bones (Morton's painful affection of the foot). It oc- 
curs in people who stand on the feet a great deal, is relieved by a night's 
rest, increases as the day goes on, and is increased by pressure or by 
wearing a tight shoe. It is worse in wet and cold weather. Localized 
pressure at the point on the sole indicated above causes extreme pain. 

We cannot leave the extremities without a word regarding pains in the 
periphery, in the extremities, of distinctly central origin, the forerunner of 
hemorrhage into the brain. Mitchell has called attention to these pains. 
They occur suddenly without evidence of local disease ; they are located 
in one of the extremities, usually the leg, are excruciating, and not 
influenced by position or local applications or pressure. Occurring in 
a patient with hard arteries and high pulse tension, they should be 
looked upon with suspicion. 

Pains of the Thorax. Painful diseases of the muscles and of the 
viscera are excluded; pains of reflex origin will be referred to. They are 
usually seated in the shoulder or the back, audaredue to liver or gastric dis- 
ease. The pain of liver disease is referred to the right shoulder ; of ulcer 
of the stomach, to the interscapular region and the lumbar region, or to 



46 



GENERAL DIAGNOSIS. 



the top of the shoulder, as in a case observed by Wood. Pain behind 
the sternum is a reflex neurosis from gastric disorder. It may occur in 
bronchitis. It may also be due to cancer of the mediastinum, to aneur- 
ism, or angina. Pain in the sternum or ribs is syphilitic or due to a 
periostitis or necrosis following typhoid fever, rarely to cancer. Chronic 
fibrous inflammation of one or more of the attachments of the muscles 
is of common occurrence. The pain lasts for years. It is persistent, 
sometimes associated with stiffness, it is increased by movement, and 
there may be extreme aching in the parts. The pain of vertebral caries 
transmitted along the course of the nerve has been referred to. 

Girdle Pain. This is a peculiar pain or sensation in the trunk due to 
disease of the spinal cord. It is described as the sensation of a band 
tightly drawn around the body. It varies from a simple drawing sen- 
sation to extreme pain which encircles the trunk. It is situated above 
the level of the umbilicus. In milder forms it is due to chronic myelitis 
or spinal sclerosis ; in severe forms, to inflammation of the nerve roots, 
or to cancerous, syphilitic, or tubercular disease of the meninges. 

Pain in the Spine. Pain in the spine is due to organic disease of 
the cord, to acute or chronic inflammation of the meninges, disease of 
the bones of the vertebral column, or to curvature of various forms 
from muscle weakness. Rhachialgia and tenderness in the course of 
the spine occur after concussion. In organic disease of the cord pain 
is referred to the loins, the sacrum, or the parts about the spine, but 
not to the spinal column itself. In the same disease of the cord we 
have the eccentric or radiating pains of which mention has been pre- 
viously made, due to irritation of posterior nerve roots. They may be 
dull, resembling those of rheumatism. In acute cases the pains are 
accompanied with febrile symptoms which may simulate rheumatism, 
especially when other spinal symptoms are in abeyance. In chronic 
cases these peripheral spinal pains are influenced by the weather, which 
likewise makes it difficult to distinguish them from rheumatism. Rheu- 
matic pains in the limbs independent of actual joint changes occurring 
particularly after middle life, should lead to examination for loss of 
power of walking properly, ataxia, and alterations in reflex action, by 
which their true origin may be recognized. In locomotor ataxia sharp 
and darting pains occur, "pain crises," and girdle sensations. 

Fixed localized pain at some point in the vertebrae when not due to 
other conditions points to local caries, or may be of syphilitic or tuber- 
cular origin, or due to pressure, as by an aneurism. 

Pain due to vertebral disease is both local and radiating, it is increased 
by pressure directly on the spinal column (on the head), by heat or cold, 
or by electricity applied over the part. It is relieved by removing the 
pressure of the weight above, as by raisiug the head or shoulders. It 
is increased by pressure or a jar on the head. It is relieved by the abso- 
lutely recumbent posture. The movements (flexibility) of the spine are 
interfered with ; there is local spasm of muscles ; there may be deform- 
ity. When the patient is placed upon a flat surface the normal lumbar 
arch is changed. The pain of curvature from muscular weakness extends 



THE DATA OBTAINED BY INQUIRY. 



47 



along nerves, is afebrile, without signs of organic disease above men- 
tioned, but with muscle weakness, and general signs of debility. Pain 
due to meningeal disease is local and radiating. It is associated with 
muscular spasm and stiffness of the spinal column. 

Pain in the Side. One of the most frequent sources of pain of 
which complaint is made to the practitioner is pain in the left side — the 
so-called infra-mammary pain. By a discussion of it we can show how 
pain, as a symptom, must be investigated in order to determine the 
tissue affected and the nature of the disease. The tests used in the study 
of nerve affections (q. v.) are not given. It may be due to many causes, 
to exclude any one of which inquiry as to the mode of onset, duration, 
and character of the pain must be made. The structures underneath 
and about the seat of pain must be examined. 1. The skin: to exclude 
any swelling or tumor or herpes zoster, and to determine the tender 
nerve points. 2. The muscle: to exclude myalgia or pleurodynia. Ex- 
amine for tenderness ; note the effect of movement ; does full breathing 
increase the pain ? Palpate with the fingers and the whole hand. Negative 
answers exclude any muscular affection. 3. The nerves, (a) Tender 
points; (6) herpes; (c) other vasomotor appearances. 4. The pleura. 
Auscultate for friction, if pleuritis. Inquire for cough. Note the char- 
acter and effect of breathing. 5. The pericardium. Note friction of peri- 
carditis or thrill by palpation. Is the heart disturbed in function? 6. The 
heart. It is rare that disease of this organ causes pain, although it may 
be present in dilatation. Is it affected in a reflex manner, causing pal- 
pitation or irregularity? Look for distant disease. 7. The stomach. 
A dilated stomach may, by pressure upward, or gastric disorder in a 
reflex manner, cause pain. 1 8. Examine the vertebra for disease of it, 
or pressure upon it by aneurism. 9. The blood, for anaemia. 10. 
Toxaemia. Inquire for its presence; particularly malaria, rheumatism, 
lead, etc. If a local cause is not ascertained look for central nervous or 
reflex disorder. The above course must be pursued in this, and should 
be pursued in all cases of pain. 

Although any one of the above conditions may cause pain in the side, 
it is usually — 1, a reflex pain from gastric disorder; 2, pain from neu- 
ritis; 3, a true neuralgia, from anaemia ; 4, a neuralgia from heart fatigue. 
(Hilton.) 

It is to be observed that every local tissue must be examined, and 
questions asked as to the various attributes of the pain. 

Pain in the Loins. When acute, without fever, it may be due to 
lumbago, to a sudden uterine retroversion, to a suddenly moved kidney, 

1 Shoulder-tip pain, due to anastomosis of phrenic nerve with 3d and 4th cervical and to parts 
of liver and round ligament (Hilton) ; or of phrenic nerve and subciavius (Rolleston) ; or of vagus 
with spinal accessory, which communicates with 3d and 4th cervical. The v. and s. a. are sensitive 
to pressure. (Embleton.) 

Infra-mammary pain (6th, 7th, and 8th intercostal spaces). The aorta at left side, 3d dorsal verte- 
bra, is in relation to the 4th, 5th, and 6th intercostal nerves through the sympathetic ganglia, 
through which also the heart sympathetics are in anastomosis. The 4th, 5th, and 6th intercostal 
nerves supply cutaneous branches to the 6th, 7th, and 8th intercostal spaces. The infra-mammary 
pain is a reflex neuralgia expressive of some heart distress. The latter is brought about by ex- 
haustion of the medullary and vasomotor centres, from worry or overwork, or from long-continued 
irritation of the uterine nerves. In leucorrhoea this pain is most common. (Jacobson ; Hilton on 
" Rest and Pain.") 



48 



GENERAL DIAGNOSIS. 



or calculus of the kidney ; with fever, acute Bright's disease, smallpox, 
muscular rheumatism, tonsillitis, influenza or spinal meningitis must be 
looked for. 

Chronic Pain in the Back ; Backache. This may be due to 
many causes. The cause varies with the seat of the pain. When 
in the region of the kidneys, they should be examined. Organic dis- 
ease (Bright' s) may be associated with backache; more frequently pain, 
if in one kidney, is due to a calculus or to accumulation of uric-acid 
gravel. It may be constant in moved or movable kidney. When low 
down, just above or over the sacrum, it is due to disturbance of the 
pelvic viscera. The uterus, the rectum (impacted, cancerous) must be 
examined. 

Otherwise we may have — (a) Pain due to affections of the muscles. 
1. Myalgia of rheumatic origin. Increased by movement, by damp- 
ness, by pressure. Often relieved by warmth, by the recumbent pos- 
ture or rest. It is associated with symptoms of lithsemia and of the 
passage of red sand in the urine. When the fascia is affected, or the 
ligaments of the vertebrae, the upright position and pressure in small areas 
increase the pain ; other muscles may be affected alternately. 2. Myalgia 
from sprain. A history of injury is obtained. Usually one side greater 
than the other. Tenderness is present and movement increases the pain. 
There may be increased swelling, vasomotor disturbance, or ecchymoses. 
Neurosis (hysteria) attends the pain. 3. Myalgia from fatigue. Not 
only acute fatigue after exertion, but chronic muscle tire (and nerve 
tire). The pain is increased on exertion, after mental, physical, or emo- 
tional effort. The muscles are flabby ; the vertebral column is not 
supported. The patient lounges or supports the back. Deformities 
are observed. Neurasthenia, ancemia, and local exhaustive disease 
(uterine, gastro-intestinal, etc.) are present. 

(6) Pain due to affections of the nerves. Nerve pain is recognized by 
the tender points ; by vasomotor phenomena. 

(c) Pain due to disease of the spine, the membranes, or the cord. 
(See above.) 



CHAP TEE III. 



THE DATA OBTAINED BY OBSERVATION. 

The objective symptoms correspond to phenomena in nature. Method of procedure for 
determination as to patient ; method of the observer. Inspection, palpation, per- 
cussion. The instruments required. Examination of the exterior. Gen- 
eral examination. The first-sight impression. The temperament and con- 
stitution. Apparent age. Effects of habits and occupation. The attitude and 
gait. General form and nutrition. Changes in size and weight. From the 
amount of adipose tissue — obesity — emaciation. Changes in the skeleton. En- 
largement — acromegaly — osteitis deformans — pulmonary osteo-arthropathy . 
Diminution — rhachitis — osteomalacia. The exterior in general. The skin. 
The color — redness — pallor — jaundice — cyanosis — the bronzed skin — Addison's 
disease — chloasma — tinea versicolor — vagabond's disease — argyria — freckles. 
The nutrition. Moisture and dryness — hyperidrosis — anhidrosis. Scars. Hemor- 
rhages — mode of recognition — cause — significance. Eruptions — their clinical 
significance — nature of the lesion — distribution — associate morbid phenomena — 
general symptoms. Table of skin diseases. Erythema — herpes — erythema 
nodosum — urticaria — medicinal rashes — erythema of infectious diseases — roseola 
— miliaria or sudamina. General diagnosis. The subcutaneous connective tissue. 
(Edema — causes — mode of recognition — situation — feet, face, arms and head — 
oedema of trichinosis — angio-neurotic oedema. Myxoedema. Connective tissue 
dystrophies. Scleroderma. Sarcomata — cysticercus cellulosse — brawny indura- 
tion. Subcutaneous nodules. The temperature. Fever. Causes of body heat 
and fever — mode of determination — physiological variations — pathological 
variations — the types of fever — the course of the fever — initial stage, fastigium, 
defervescence — crisis — lysis— the daily range — recrudescence. The symptoms 
of fever. Subnormal temperature. The diagnostic significance of fever. The 
general musculature. General abnormal vital conditions. Fits or seizures — 
coma — collapse — shock. Local examination of the exterior. The face — the 
facial expression — the head — facial hemiatrophy — the hair — the cranium. 
Hydrocephalus. The Hps. The eye. The ear. The neck — the thyroid gland, the 
bloodvessels of the neck. The extremities — ha?ids 7 skin, progressive muscular 
atrophy — lead-poisoning, rheumatoid arthritis, athetosis. Fingers. Heberden's 
nodosities — contraction of fascia — Dupuytren's contraction — deviations in shape. 
The nails. Tropho-neuroses — cold hands and feet — Raynaud's disease — 
erythromelalgia. The lymphatic glands. The muscles. Myositis — idiopathic 
muscular atrophy — pseudo-hypertrophy — Thomsen's disease — paramyoclonus 
multiplex. The bones. Nodes. They are the physical expression of present 
disease, or of the ravages of past affections. The joints — synovitis — rheumatism — 
gout — rheumatoid arthritis — the tabetic joint — the hysterical joint — special 
joint affections. Diagnosis. 

The Objective Symptoms. The objective symptoms of disease are 
the most important to ascertain. They are the " handwriting on the 
wall." The impress of forces for good or evil is observed. In deter- 

4 



50 



GENERAL DIAGNOSIS, 



mining them we also determine the condition of the organism ; its state 
after the action of the forces of its environment. The physical and 
mental status of the being is measured. He is individualized. The 
objective symptoms are data by which a complete diagnosis is made. 
Without such data the diagnosis is guesswork — one of probability. 
With such data alone, if accurately, precisely collected, a positive diag- 
nosis very frequently can be made. A correct diagnosis depends upon 
the skill and thoroughness of the physician and his ability to interpret 
the data secured, always provided that clear, succinct data can be 
obtained. 

The data obtained by inquiry, within the limitations previously indi- 
cated, if such exist, are recorded and then the data obtainable by obser- 
vation are to be looked for. A physical examination of the patient must 
be made, followed by an immediate study, or, if time permits, a study 
at leisure of the fluids of the body, microscopically, chemically, and 
bacteriologically. By the physical examination a general survey of the 
individual, including an estimation of the height and weight, is made, 
and all the organs interrogated by the senses applicable to the investiga- 
tion of each, with the special instruments devised for aiding them. The 
natural secretions and discharges, abnormal discharges, all exudations 
or transudations, and cystic fluids are passed upon. 

The student will soon learn that the process of ascertaining the 
objective signs of disease is in no respect different from that which 
obtains in the study of any objects in nature or any life phenomena. 
The chemist notices the form, the color, the density, etc., of the object 
under examination ; the effects of heat and cold, of various reagents 
upon its structure ; determines its component parts and ascertains its 
relation to other objects in nature. From data thus derived by the use 
of all his senses he classifies the object. The biologist not only notes 
the physical appearance of a given form of life, but also notes the phe- 
nomena of the living, sentient matter under all conditions in a varied 
environment. By comparison and analysis, the living being is classified. 

By the same powers of observation and the same analytical process, 
the departures from health are recognized and classified. Is it not, 
therefore, a wonderful aid to the diagnostician to have had trained pre- 
viously, by observation in allied sciences, the faculties which contribute 
to the development of these powers? 

What has been thus imperfectly said is ntended to emphasize the 
fact that no mystery attends the recognition of the objective signs of 
disease. Patient training, skill in technique, and opportunities of 
observing disease at the bedside are essential. 

Method of Procedure. The method by which the data ascertained 
by observation are secured is modified by the circumstances under which 
the patient is seen. It is obvious that the patient who comes to the office, 
or is not sufficiently ill to be in bed, has sufficient strength to stand, and 
should be given an exhaustive examination. Moreover, we can inquire 
into certain abnormalities, as the gait, not visible in bed. On the 
other hand, from the bed-patient we learn of the position he assumes 
when lying down, and have better opportunities for thorough examina- 



THE DATA OBTAINED BY OBSERVATION. 



51 



tion of the various organs. Often the objective examination must be 
very brief on account of the extreme illness of the patient. It may be 
advisable, although unfortunate, to exclude one or more methods, as 
percussion if there is pain, or auscultation if there is great restlessness 
or orthopnoea. 

If a complete examination is made, it is well to begin with the 
exterior. After the external examination is made, the internal examina- 
tion is conducted, by grouping together and examining organs function- 
ally related, as the heart and bloodvessels in diseases of the heart ; the 
nose, larynx and lungs, in diseases of the latter. The student may well 
begin at the head and take up organs in their continuity. 

Comparison. The results attained by observation are based upon 
comparison ; the student must bear this constantly in mind. We 
compare the body as a whole with our conception of the normal 
individual formed by a study of a large number of persons. We 
compare symmetrical parts — the right side of the chest with the left, 
the arm suspected to be the seat of disease with the healthy arm, etc. 
The cardinal rule in an examination is to base the significance of ascer- 
tained facts upon comparison with known normal conditions. 

Methods of Observation. Securing' the Data. To accomplish 
these ends, examination is made by the sense of sight (inspection) • by 
the sense of touch (palpation) ; by the sense of hearing (auscultation) ; 
and by the sense of hearing applied to the discrimination of sounds 
developed by percussion. By percussion or tapping the part, we also 
elicit the peculiar phenomena known as reflexes. 

The sense of taste is not used to determine the objective phenomena 
of disease. By the sense of smell some data are ascertained, as the odor 
of the exhalations and discharges. 

Inspection. By inspection we judge of the physical condition of 
the whole or a part of the body, as seen in the shape and size and in the 
color ; of the vital condition by the expression of countenance, by the 
character of the movements of the body as a whole or in part, by the 
position in bed, and by the gait. The appearance of fluids (blood) and of 
discharges is also observed. Accuracy of the results of inspection as to 
size is obtained by the use of scales to secure the weight. 

In order that the data obtained by inspection may be complete 
and accurate, every portion of the body, and of its internal cavities 
which can be seen by the unaided or aided eye, should be inspected. 
The clothing should be removed and, bearing in mind the proprieties, 
the whole body should be examined. For this purpose the patient 
should be under a good light. The light should always fall directly 
on the surface. The entire surface, of course, need not be exposed at 
once, and circumstances may be such that only one portion need be 
examined. Nevertheless, the fact must be insisted upon that patients 
who have been ill for a considerable time, as well as all grave cases, 
should be examined all over. It is even more important to do this 
if the patient is comatose. A node on the tibia, undue prominence 
of the vertebrae, a special rash about the anus, may teach a lesson 



52 



GENERAL DIAGNOSIS. 



which could not be obtained in any other way. It is assumed that the 
patient has been examined lying down. In nervous diseases and dis- 
eases affecting the muscles and bones, observation should be made of 
the gait of the patient, his ability to stand, the method of rising or 
assuming a sitting posture, and the performance of other customary 
physiological acts. For this purpose, as above intimated, portions of 
the body can be covered, or a light gown should cover the patient from 
head to foot. 

Method of the observer. In order further to secure the data in full, 
the student should teach himself a method of observation which shall 
include all the facts that can be ascertained by inspection collated in 
regular systematic order. Whether the examination is general or local, 
whether the whole of the body is referred to or only a part, as for 
instance the nose, the student should accustom himself to make obser- 
vations in the following order : First, the shape or contour (expression) ; 
second, the size ; third, the color ; fourth, the movability and the physio- 
logical condition of the part on movement. If this plan is pursued, 
little, if anything, will be overlooked. A similar order in the investiga- 
tion applies to the estimation of the character of the secretions and ex- 
cretions of the body. 

Inspection of special regions. In the inspection of special regions, in 
addition to ordinary light, artificial light and special instruments are 
required. The artificial light should be that which is secured from an 
Argand burner or from a gas-jet with a reflector, or from electricity. To 
facilitate the examination, the room should be darkened and head- 
mirrors used as reflectors. A number of these have been devised, any 
one of which is suitable if it fits the head well and can be adjusted with 
comfort so that the observer can throw the light on the part he wishes 
to examine, and at the same time peer through the centre of the mirror. 
A special arrangement of the patient and the light is required. The 
patient should sit in an easy, comfortable, erect position, with the light 
on a level with the part to be examined, a little behind and to his right 
or left, according to the convenience of the operator. Special apparatus 
is required for the examination of each cavity : mirrors, tongue de- 
pressor, and specula for the throat, an ophthalmoscope for the eye, etc. 
(See respective sections.) 

Palpation. The results of inspection are always confirmed when pos- 
sible by palpation, the sense of touch supplying also additional data. 
The nutrition of the parts is ascertained. The density, the resistance, 
the special character of the part as indicated by the density, whether solid 
or liquid, are determined by this method of examination. On examina- 
tion of the skin, the degree of dryness or moisture; the character of the 
skin, whether smooth or rough ; the density of the part, as to degree of 
thickness and resistance, are all ascertained by means of the sense of 
touch. The presence or absence of pitting is observed, and the nature 
of swellings ascertained. In a similar manner local areas are examined. 
The same routine method should become habitual with the student. First, 
the shape and contour; second, the size ; third, the character of the color, 
its change on pressure, etc.; fourth, the movability of the part, and 



THE DATA OBTAINED BY OBSERVATION. 



53 



the character of the normal movements, as when a joint is under obser- 
vation; fifth, the resistance and density of the part examined, or special 
characteristics revealed by touch — the elasticity of skin, firmness of 
muscles, and in swellings the presence or absence of fluctuation. 
In addition to the above, other phenomena are detected which belong 
more particularly to the living body. By palpation, alone or with 
instruments, we determine the sensibility of the part, the presence or 
absence of tenderness, the temperature and the degree of moisture. 
In the examination of special regions by means of palpation some 
phenomena are determined peculiar to the system under examination, 
and dependent upon its physiological or functional action. Thus in 
palpation of the chest, in addition to its movement, we note the 
vibrations transmitted to the hand when the patient is asked to speak, 
or detect abnormal vibrations from the friction of two rough surfaces 
together (pleura), or from the throwing of fluids into agitation : fremitus, 
friction, and r&les are thus transmitted. 

Knowledge of the action of the heart and of its position is ascertained 
by palpation ; thrills are detected, abnormal impulses felt. (For method 
of procedure, see respective organs.) 

Auscultation. By auscultation, we ascertain and analyze the sounds 
that attend the physiological performance of such organs as produce 
sound : the lungs, the heart, and the bloodvessels. Abnormal sounds 
may be created in the pleura and pericardium aud in hollow viscera, 
as the oesophagus, stomach, and intestines, and their presence is ascer- 
tained by auscultation. (For methods, see under Diseases of the Lungs 
and Heart.) The character of the voice is also studied for abnormalities 
in the respiratory tract, which are indicated by change in the quality or 
loudness of speech. 

Percussion. By percussion we strike over organs and elicit sounds 
which indicate the physical condition of the part percussed. In health 
the lungs and the gastro-intestinal tract contain air in certain definite 
relations, and therefore the sounds yielded by percussion are always of a 
definite character. Any change from the normal sound is indicative of 
disease, of abnormal structure, or of alterations of the normal relations 
of the parts. Percussion determines these changes, and in addition we 
are enabled to estimate the size of organs. It is possible to determine 
the size of the liver, the heart, or the spleen, because of the relationship 
of these airless, non-resonant bodies to the air- containing structures 
around them. As this method of securing data is of greater use in 
pulmonary and abdominal diseases, the mode of procedure will be de- 
scribed under chapters upon diseases of the lungs and abdomen. 

In addition to the data obtained by the above methods, valuable and 
essential data are obtained by chemical, microscopical, and bacterio- 
logical examinations of the fluids, discharges, exudations and transuda- 
tions, and by aspiration and special examination of the fluids obtained 
from the natural cavities or from cysts of the body. Bacteriological 
diagnosis and exploratory puncture will be considered in a special 
chapter. 



54 



GENERAL DIAGNOSIS. 



The Armamentarium. The following instruments are necessary to 
conduct ordinary methods of investigation : 

To aid the eye, we have the microscope ; various reflectors and mir- 
rors to illuminate cavities, as the ophthalmoscope, the laryngoscope, and 
the otoscope ; specula of various kinds, and forms of illumination, as the 
Argand burner or electric light. 

To aid the touch or confirm its findings, the thermometer, the tape- 
measure, the cyrtometer, the dynamometer ; the plessor to ascertain 
reflexes ; the sesthesiometer to determine the keenness of sensation ; 
sounds for the oesophagus ; probes for the nares ; the sphygmograph for 
the pulse. 

To ascertain the nature of the contents of a swelling or tumor, or of 
the natural cavities of the body, the exploring needle and aspirator are 
used. The contents of the stomach, the bowels or the bladder must be 
obtained often, and for this we use tubes or catheters, the fluid being 
withdrawn by suction or by siphonage. 

The sounds that are elicited in order that the sense of hearing may 
be utilized are evoked by the use of a plessor and pleximeter, and are 
localized and differentiated by the stethoscope, of which there are many 
varieties. 

For the examination of the blood, special instruments are employed — 
hsemocy to meter and haBmoglobinometer ; for the urine and other fluids, 
chemicals, specific gravity bottles, etc. ; and for bacteriological research, 
the various appliances that appertain to such investigations. The in- 
struments above mentioned will be detailed in the respective sections, 
and their method of employment indicated. 

The Microscope. This instrument is employed for the investiga- 
tion of the phenomena of disease in nearly all the organs or tissues. It 
is absolutely essential for clinical work. It need not be described. It 
is enough to say that lenses which amplify from 50 to 1500 diameters 
should be secured, an oil-immersion objective, and an Abbe condenser. 
Low powers are necessary for the study of plate cultures, and for the 
inspection of comparatively large objects in the urine, sputum and faeces. 
High powers are necessary for bacteriological work. The diaphragms 
must be used with the Abbe condenser. 

Data obtained by Examination of the Exterior. 

The examinations are made by inspection and palpation (see above). 
All clothing should be removed and the examination made in a good 
light. Comparisons of the two sides of the body should always be 
made. The examination is both general and local. 

External changes due to or associated with disease of special systems are 
considered under the examination of the system concerned, as the bony 
surface and bones (contour) of the thorax in the examination of the re- 
spiratory system, the abdomen inthe examination of the digestive system. 

A. General Examination of the Exterior. 

The general appearance of the patient affords an idea of the ability 
with which he has been able to cope with the antagonistic forces of his 



THE DATA OBTAINED BY OBSERVATION. 



55 



environment, or to overcome the deleterious effects of his occupation, or 
indicates the effects of present or past disease or of disease derived by 
heredity. The first sight, striking impression, is always to be noted. 
"Very sick," "comatose," "collapsed," etc., or "robust," "cyanosed," etc., 
are speaking memoranda. To the experienced practitioner, the opinion 
formed by the first glance is often of great diagnostic significance. 

We then note — first, the temperament and constitution of the patient 
or the evidence of any diathesis or cachexia ; second, the apparent age ; 
third, the indications, from his appearance, of the habits and occupation 
of the patient ; fourth, the position assumed in standing, walking, or in 
bed ; fifth, the general form and nutrition ; sixth, the occurrence of 
fits, coma, collapse, or shock. 

A general review of the exterior will often indicate the probable sys- 
tem that is the seat of disease. For instance, violent respiratory action 
points to the lungs, paralysis to the nervous system, the enlarged ab- 
domen to disease of viscera of that region. 

1. The Temperament and Constitution of the Patient. Informer 
times emphasis was laid upon general appearances as indicative of 
a particular diathesis, or inherited constitution of the patient. Five 
varieties of diathesis were described to which general appearances 
pointed. They were the gouty or sanguine arthritic, the strumous, the 
nervous, the bilious, and the lymphatic diatheses. While certain ap- 
pearances point to the occurrence of groups of individuals who may be 
classified under one of these diatheses, it is well not to lay too much 
stress upon them for diagnostic purposes. Certainly, as pointed out 
by Gairdner, it is not proper, after a survey of the patient, to note the 
presence of any particular diathesis in so many words — as the lym- 
phatic diathesis. The student should teach himself to note individual 
appearances, and after a complete examination is made or the light of 
experience supports him, draw a final conclusion as to the diathesis. 

In the gouty or sanguine diathesis, the osseous system and muscles 
are well developed, the nutrition active, and the patient usually robust 
in appearance. The digestion is good, respirations deep, the circulation 
is well carried on, as shown by the florid skin and the large heart ; the 
pulse is firm and steady, and the pressure in the arteries is high. The 
head is large and the jaw prominent, the teeth good. The hair is strong 
and thick. The individual with such diathesis is predisposed to the 
arterial changes of advancing age. Apoplexy, aneurism, and angina 
pectoris, or resulting complications of the senile changes in the heart 
and arteries, develop. 

In the strumous diathesis the appearance of bones, the glandular 
system, and the face are expressive ; the bones of the chest are small ; 
the long bones are slender, while their epiphyses are large ; the fore- 
head is broad and prominent, the lips full, the alse nasi thick, the teeth 
are carious, the lower jaw light and thin, the hair is fine and often of a 
light hue, the eyelashes long, the eyebrows arched, often heavy. In 
this diathesis the nutritive changes are poor, inflammations are usually 
sluggish ; disease of the bones, of the glands, and forms of tuberculosis, 
are liable to be more severe. 



56 



GENERAL DIAGNOSIS. 



In the nervous diathesis we see small, active, restless beings, with 
small bones and large muscles. They are full of energy, and carry on 
large business or mental operations. The features are well formed, the 
eye active. They are the subjects of overwork and early breaking- 
down of the nervous system, and of dyspepsia. They possess 
idiosyncrasies toward drugs, as opiates. 

In persons of the bilious diathesis, we find a dark skin, dark hair, 
muddy conjunctivae. They are usually not w T ell nourished. Their 
digestion is poor, and they are subject to so-called attacks of biliousness. 
Sick headaches are common. Fatigue is not borne well. 

In the lymphatic diathesis there is lack of energy and sluggishness 
of nutritive processes ; such persons are unable to keep up in the wear 
and tear of life. They are usually pallid aud have soft muscles. 

In addition to diatheses, cachexia? are also noted. Cachexia? arise 
from the ravages of disease and especially from such forms of dis- 
ease as cause reduction in the number of the red cells of the blood and 
diminution of the haemoglobin. The cachexia? that have been de- 
scribed are caused especially by syphilis, gout, and chronic malarial 
poisoning ; in cancer of some part of the digestive apparatus — and, 
indeed, in all forms of chronic disease of the digestive tract — a cachexia 
is seen. The anaemia that arises from lead, arsenic, and other metallic 
poisons produces an appearance to which the term cachexia has been 
applied. The special cachexia derives its name from its cause, as the 
syphilitic or cancerous cachexia. 

2. The Apparent Age of the patient should be estimated from his 
appearance and compared with the exact age when this is learned later. 
In this way the physician will be enabled to judge whether the patient is 
aging too rapidly or bearing his age well. An obvious advantage from 
noting the age of the patient arises from the fact that it enables us at 
once to exclude a large number of diseases which are not found in the 
period of life to which the patient belongs. For example, if the 
patient is a child we have not to consider the chronic degenerations 
and the visceral cirrhoses which appear in middle and later life. Con- 
versely, in an old person we do not expect to meet with the exanthe- 
mata, which affect children almost exclusively. So, too, typhoid fever 
aud consumption are more common in adolescence and early manhood 
than in childhood and old age. Again, in very young girls, the ques- 
tion of menstruation and its difficulties never have to be considered. 
Gray hair in a person under thirty-five generally indicates a feeble 
constitution and premature age. Loss of hair is not significant, for, 
apart from a tendency to baldness which is very marked in some 
families, professional men who do much brain-work, especially in hot, 
close rooms, are apt to become bald much sooner than other men. The 
presence of wrinkles at the corners of the eyes and of " crow's feet/' 
and of dull, dry, lustreless eyebrows, should be noted as indicating 
aging, whether the person has lived long or not. In women approach- 
ing forty who do not gain in flesh there is often a suggestive prominence 
of the angles of the jaw and sterno-mastoid muscles with a certain loss 
of roundness and elasticity of the cheeks. The latter appearance, how- 
ever, may be due to loss of molar teeth. 



THE DATA OBTAINED BY OBSERVATION. 



57 



3. Effects of Habits and Occupation. From the general appear- 
ance, the habits of the patient as to industry, neatness, or care of 
dress, may be observed ; they are of diagnostic importance, particularly 
in brain affections. The appearance also shows frequently whether 
the patient is addicted to alcoholism or the use of other narcotics. 

The occupation of the patient is often important in throwing light 
upon his disease ; the brown, weather-beaten face of the farm laborer, 
sailor, or driver contrasts strongly with that of the merchant, clergyman, 
or clerk. A machinist can often be recognized by his grimy, oily hands. 
All this information can be obtained by a glance, and many details can 
be added before the patient has taken his seat in the consulting-room. 

4. The Attitude and Gait of the Patient. The attitude of the 
patient gives information as to his physical vigor, and, to a certain 
extent, of his alertness of mind. A man vigorous of mind and body 
will stand firmly upon both feet, with back straight and shoulders 
square, and head erect. When one is depressed by care or disease the 
shoulders have a tendency to droop, and the head to fall forward. In- 
decision and vacillating disposition are sometimes indicated by the 
patient standing first upon one foot and then upon the other while 
talking, or by an unsteady look from the eye. 

When one shoulder is lower than the other and the patient is 
of phthisical build, pale and emaciated, the attitude is strongly sug- 
gestive of phthisis or chronic pleurisy of the side on which the 
shoulder is depressed. 

Sometimes in acute pleurisy the patient will walk with the shoulder 
depressed and the arm firmly pressed against the affected side so as to 
restrict its movements as much as possible. 

Decubitus. The attitude of the patient in bed is often significant. 
He may assume the active dorsal or side position, with the body 
arranged so that it is comfortable and unconstrained. Then slight in- 
disposition only is present. On the other hand, the side position, the 
dorsal position, or the upright or semi-upright position, may be assumed. 

To the close observer the attitude of a patient in bed is sometimes 
reassuring. He lies easily upon his back or turned slightly to one side 
with the arms uncovered, and he may even turn or sit up to meet the 
physician as he enters the room — each of which point to moderate ill- 
ness or to the onset of convalescence. 

Side Position. A patient with acute pleurisy or pneumonia will 
lie on the affected side so as to limit its motion as much as possible. 
The breathing will be shallow and frequent, the expression of the face 
anxious, and occasionally a spasm of pain contracts it as the patient 
coughs or is obliged to take a full breath. He usually lies on the 
affected side because fixation is thus secured and pain on inspiratory 
movement diminished, and also because there is greater liberty for ex- 
pansion of the free healthy side. If effusions are present, by lying on the 
side of the effusion pressure is removed from the heart and the unaffected 
lung, an obvious point of advantage. 

At times in cases of thoracic aneurism, if situated on one side, or of 



58 



GENERAL DIAGNOSIS. 



movable thoracic tumors, the patient will lie on the side which is the 
seat of the disease. 

The dorsal position assumed in health or slight disease has been 
referred to. When the position is assumed in grave disease the term 
passive is applied to it because it is often assumed without the volition 
of the patient. 

In grave cases of typhoid or other low fevers, the patient lies upon 
the back and shows a marked teudency to slip down in the bed. The 
expressiou of the face is heavy or vacant. The lips and teeth require 
constant cleaning to keep them from sordes ; the tongue is dry and 
glazed or covered with sordes ; the tendons of the wrists twitch con- 
vulsively, and the patient lies with open or half-open eyes (coma 
vigil), picking at the bedclothes or at imaginary objects which float 
before his eyes. 

A healthy baby a few months old finds motion an almost ceaseless 
delight. It will lie on its back, kick up its feet, play with its toes or 
some object that attracts it, crowing, wriggling, squirming. In rickets, 
on the contrary, the little patient lies as quiet as possible, even refrain- 
ing from crying because all motion is painful. In cerebro- spinal 
meningitis the head is drawn backward and downward and the 
muscles at the back of the neck are rigidly contracted. 

In acute disease involving the peritoneum or neighboring organs, such 
as acute peritonitis, appendicitis, or endometritis, the patient lies on the 
back with the legs flexed upon the thighs and the thighs upon the 
abdomen. Motion is avoided as much as possible, and so is any 
pressure upon the abdomen. 

Lying in the lateral or dorsal position, with legs drawn up and trunk 
and head drawn down to meet them with groans of pain and possibly 
involuntary bearing down, is seen in hepatic and intestinal colic, and is 
suspicious of the throes of labor, if the patient is a woman. 

The Semi-upright or Upright Sitting Position. In an acute attack 
of asthma the patient is found sitting up in bed, or in a chair, possibly 
by an open window. The expression of the face is anxious, the 
skin dusky or pale and moist. The breathing is loud, noisy and 
scraping. The demand for oxygen is imperative, difficulty is experi- 
enced in inspiration and expiration, not enough air being able to 
enter the alveoli for physiologic purposes ; expiration is prolonged 
and labored (expiratory dyspnoea). The patient sits with the chin 
raised and head erect, the hands grasping the arms of a chair or the 
bedclothing, so that by fixing the chest the accessory muscles of 
respiration can be of the greatest assistance in supplementing the 
diaphragm. In emphysema, in its late stages or complicated with 
bronchitis and asthma, the same position is assumed almost constantly. 

In pericarditis with effusion, in large pleural effusions, and in advanced 
heart disease with anasarca the patient is unable to lie down on account 
of the smothering feeling which the recumbent position induces. In 
pericarditis the expression of the face is extremely anxious, the patient 
having a dread of impending death. 

In large pleural effusion the expression is not usually so anxious, but 
the dyspnoea may be intense. The patient is propped up in bed, leaning 



THE DATA OBTAINED BY OBSERVATION. 



59 



slightly to the affected side, and devotes all his energies to breathing, 
avoiding any exertions such as moving, answering questions or cough- 
ing, which tax his breathing muscles still more. One side of his chest 
may be observed to move violently while the other is motionless. 

In heart disease and anasarca, dyspnoea frequently amounts to 
orthopnoea. The patient may be found propped up in bed or seated in 
a large rocking-chair, some patients finding greater comfort in the latter. 
The face is pale, livid, or jaundiced, and may be swollen, while the 
cellular tissue throughout the body is oedematous and the cavities, 
especially the peritoneum, are more or less filled with fluid. In 
diaphragmatic pleurisy the position assumed is very characteristic — the 
erect sitting posture, with the body leaning forward and laterally, to 
relieve the pain. 

The Prone Position. Barely the patient is found lying upon the 
abdomen. When seen in this position it is because of relief to 
abdominal pain, or to colic of any form, or from relief that is given to 
an ulcer of the stomach, and aneurism, or caries of the vertebra? on 
account of the position. 

In tetanus, muscles are in a state of tonic contraction, on account of 
which an unusual position is seen known as opisthotonos, in which the 
body rests on the head and heels, the trunk being arched upward. In 
strychnine poisoning with tonic convulsions the same position may be 
assumed. 

JEmprosthotonos, vaulted side position, is occasionally assumed in 
tetanus and also in strychnine poisoning. 

Unclassified Positions. Irregular or bizarre positions are usually 
assumed in affections of the nervous system, particularly in hysteria. 

Mestlessness. Often the patient is unable to assume a position, or 
at least to remain fixed in any position. This may occur on account of 
pain, or because of irritation of the nerve centres previously described. 
In cases of moderate cerebral hemorrhage, and of shock, there is great 
restlessness. The patient is restless without the appearance of agitation. 
In profuse hemorrhage, whether uterine, intestinal, or pulmonary, on 
account of cerebral anaemia, there is also restlessness with sighing 
and gasping. The pallor that attends the hemorrhage, the quicker 
pulse, the great thirst, with the history of bleeding, are sufficient to 
explain the restless state. In chorea there is more than restlessness, 
there is constant twitching of muscles with jerking from one side of the 
body to the other. The patient does not keep the covers on and in her 
agitation often does herself considerable injury. 

In cerebral meningitis the patient tosses from side to side, or lies with 
the head retracted and pressed deeply into the pillow. The eyes are 
injected, the pupils contracted, and frequent sharp cries are uttered, 
especially if the patient be a child. 

In hysterical convulsions the patient, usually a young woman, tosses 
wildly to and fro, screaming, laughing, or crying ; or coma may be 
mimicked. The moods change often with great suddenness. The ap- 
pearance is very alarming at first sight ; but the pulse and breathing are 
not much accelerated, there is no fever, and the patient is conscious 
enough not to injure herself even to biting the tongue. 



60 



GENERAL DIAGNOSIS. 



The Gait and Station. Both are of great significance, particularly 
in the study of nervous diseases. The terras astasia and abasia are ap- 
plied to the loss of power of standing and of walking respectively, with- 
out paralysis. Both are usually functional or hysterical. 

The gait is sometimes characteristic. The hemiplegia patient ad- 
vances the sound limb, and then brings the other up to it by lifting the 
pelvis and swinging the paralyzed limb round by a movement of 
circumduction. The shoe is worn down at the toe in an irregular 
way. Sometimes the shoulder on the sound side is thrown outward 
and forward so as to facilitate the raising of the pelvis on the paralyzed 
side in order that the limb may be circumducted. The arm may be 
rigid or bent at the elbow, the fingers being flexed upon the palm, and 
the thumb turned in. 

In locomotor ataxia there is uncertainty in the gait, which may only 
be felt by the patient or be apparent to the observer also. There is 
irregularity in the line of progression, or the movements become very 
jerky and erratic. As there is very little motion at the knee, because 
it is spasmodically braced, the pelvis is slightly tilted until the foot is 
released ; the foot is then raised unnecessarily high, jerked rapidly for- 
ward and outward and brought down with a sudden stamp, or flail-like 
action, on the heel. The patient's centre of gravity undergoes several 
changes at each step, so that he swings from side to side. He cannot 
walk in the dark, and at a later stage requires the aid of canes to prevent 
him from falling forward. 

In paralysis agitans the attitude and gait of the patient are peculiar. 
The head and body are thrown forward and fixed in that position ; the 
arms are slightly abducted and partly flexed, the hands being in the 
position in which a pen is held. The legs are also bent at the knees. 
Rhythmical tremors affect the hands first, and then the rest of the body, 
the head and neck usually escaping. On attempting to walk, the gait is 
festinating, that is to say, each step becomes more rapid than the preced- 
ing, until the patient is prevented from falling only by catching some- 
thing. The tremors cease during sleep, and are independent of volun- 
tary motion. 

In spastic paraplegia the patient walks with two sticks. He leans 
on the left one, arches the back, and then lifts the pelvis and the right 
limb as far from the ground as possible, but cannot quite clear ir. 
The toe has a marked tendency to stick to the ground, and is brought 
forward with a scraping sound. The knees have a tendency to inter- 
lock, and the foot which is brought forward is apt to cross in front of 
the other. 

In disseminated insular sclerosis the gait is somewhat jerky and 
resembles the gait of ataxia, or of tumor of the cerebellum. Of course 
the recognition of the disease that causes such peculiarity in gait cannot 
be made without observation of the mental and . nervous phenomena 
that attend such affections. In hysterical paraplegia there is some- 
times complete loss of power of standing or of walking. The patient 
will fall if an attempt is made to compel her to stand. Or she will 
walk with the knees and the hips semi-flexed, or in awkward attitudes, 
implying muscular effort greater than that needed for the normal gait. 



THE DATA OBTAINED BY OBSERVATION. 



61 



It is recognized by the fact of its occurrence in young subjects in whom 
are observed other striking phenomena of hysteria. 

Cross-legged progression. This form of gait is seen in children 
with spastic paraplegia, and occurs because of contracture in the calf 
muscles. When the child begins to walk, one foot gets over in front of 
the other, or swinging oscillation of the body occurs, which may persist 
through adult life. 

The gait of pseudo-hypertrophic muscular paralysis is known as the 
waddling gait. This oscillating character is assumed in order that the 
body be so inclined "as to bring the centre of gravity over each foot on 
which the patient successively throws his weight, because the weak 
gluteus medius cannot counteract the inclination toward the leg that is 
off the ground, unless the balance is exact." (Gowers.) 

The position assumed in getting up from the floor, as described by 
Gowers, is pathognomonic. The patient turns over in the all-fours 
position, raises the trunk with his arms, rests the trunk upon the 
extended hands, then extends the knees, pushes back with the hands 
until he can grasp one knee with the corresponding hand, then grasps 
the other knee and pushes up the trunk by gradually raising the point 
of support for the hand upon the thigh. The gait of paramyoclonus 
multiplex and of Thomsen's disease is also peculiar. (See Muscles.) 

Station. Ataxic astasia in locomotor ataxia. The inability to stand 
is observed under many circumstances. Either with (1) the eyes closed, 
or (2) the eyes open and the toes and heels in contact, or (3) with the eyes 
open and feet apart. The latter occurs in the highest degree of ataxia 
and may be followed later by complete loss of power of standing. 
Swaying. If a healthy person stands with the eyes shut the body will 
sway slightly. In a patient with locomotor ataxia swaying is seen in 
increased degree. 

In pseudo-hypertrophic parcdyis, if the patient stands, lordosis is seen. 
It disappears entirely when the pelvis is supported, which occurs when 
the sitting posture is assumed. In the later stages of this affection 
there is posterior or lateral convexit) 7 of the spine with astasia. 

In the paroxysms of Meniere 's disease the loss of power of standing 
may be absolute. The patient may be hurled to the ground, and be 
quite unable to rise or sit up. The nature of the paroxysm is suspected 
on account of the sudden onset and the complaint of vertigo, along 
with the ear symptoms that attend this affection. 

In disease of the middle lobe of the cerebellum, swaying from side to 
side, or in large waves, is observed. The appearance is like that of a 
drunken person. While the walk is peculiar, the patient can usually 
sit up. 

5. General Form and Nutrition. The general form and nutrition of 
the body are estimated by the color of the skin, the amount of subcu- 
taneous fat, the degree of muscularity, the size and shape of the osseous 
system. In other words, the degree of robustness is ascertained by the 
color and the size and shape, including the weight, of the individual. 
From the above estimation we ascertain the degree of development of 
the individual. To recognize lack of development is often to be able 



62 



GENERAL DIAGNOSIS. 



to explain phenomena of a functional nature which otherwise could 
not be done. The color will be considered under the head of the con- 
dition of the skin. 

Importance of such observation. It is extremely important that these 
observations should be made, particularly in childhood and adolescence. 
Not only are marked departures from the normal significant, but slight 
deviations point to the occurrence of processes which modify nutrition. 
It frequently happens that it is impossible to explain the occurrence of 
some functional disorder, as neuralgia, or of derangement of the viscera, 
or of indefinable ill health, in which the patient has inaptitude for exer- 
tion or inability to conduct the usual affairs of life. The recognition 
of malnutrition as shown in lack of tone of muscles, or diminution of 
weight, is often sufficient to point the way to successful treatment by 
general methods. 

The Size and Weight. Change in size may be general or local. 
General increase or diminution in size is due to enlargement or dimi- 
nution of the bones, muscles, aud fat singly or combined. The term 
emaciation is applied to atrophy of fat and muscles when it is in excess. 
If it is accompanied by a great loss of strength the term marasmus is 
employed. When large accumulations of fat take place the word obesity 
is applied to the condition. The estimation of the proportionate size of 
the patient to his weight is usually based upon the amount of subcu- 
taneous fat. The general accumulation can readily be recognized by 
rotundity of the exterior. Variations in size, however, may in addition 
be due to changes in (1) the skeleton, (2) muscles, or (3) adipose tissue, 
or (4) to accumulations of serum, or (5) abnormal tissue, as mucin 
underneath the skin, or (6) from connective tissue dystrophies in the 
same region. Consideration of the latter causes will be postponed ; that 
which here follows refers to the amount of fat and to a certain extent 
of the muscularity. 

Their size affords some information as to the degree of development 
of our patients and as to the class of disease to which they are most 
liable. While there is no absolute standard by which to compare the 
relative proportion of height to girth in individual cases, yet there is a 
type generally recognized as being usual, and variations from it give rise 
to such expressions as stout, spare, slender, thin, tall, and short. Stout 
usually expresses an increase in girth and a moderate excess of flesh 
over the normal. When used in this sense it becomes synonymous with 
lusty, and indicates an increase of flesh which is well distributed and 
due to a healthy, active nutrition without impairment of physical 
activity. In some cases, especially in women, stoutness is used as a 
euphemism for corpulency, but not often for that excess of fat properly 
called obesity. Stoutness in the sense of lustiness up to middle life is 
an indication of physical and often of mental vigor. It is often found 
in gouty and rheumatic subjects. A tendency to take on flesh after the 
age of forty-five, especially if the person's occupation is sedentary and 
his habit of body inactive, is not to be regarded as favorable. It may 
be compared to a warrior's persisting in wearing an increasingly heavy 
weight of armor after the campaign is over. Increased weight under 
such circumstances is not increased strength, but increased burden, and 



THE DATA OBTAINED BY OBSERVATION. 63 



the burden becomes greater with advancing years. Those who are 
stout in the sense of having too much fat in proportion to bone and 
muscle, bear fevers and exhausting diseases poorly under forty. 
Women at the menopause are very prone to take on flesh rapidly. Fat 
subjects after middle life, and to an increasing degree after that period, 
are liable to fatty degeneration of the heart, bloodvessels, and important 
viscera. 

Persons who are tall and thin, especially if they have become tall 
rapidly after puberty, are commonly looked upon as delicate, and as 
especially liable to consumption. There is reason for this view. But 
if they live to be twenty-five or more without disease of the lungs or 
pleura they may then live to a great age. 

Some patients have an appearance which is well described and under- 
stood by the word " spare." The form is compactly put together, but 
with small bones and a scanty allowance of fat. There is a tendency to 
leanness rather than to roundness of form. 

In still others, muscle and bone predominate, and the form is apt to 
be angular, such as those described as wiry. They are often possessed 
of great muscular power and resistance to strain. Those of spare and 
wiry habit bear disease very well. Inspection alone may leave one in 
doubt whether to regard an individual as thin and delicate or spare. 
Light will be obtained from the patient's occupation and the amount 
of physical exertion of which he is capable, and also from the tonicity 
and hardness of his muscles. If one stops to think a moment he will 
see that for the same amount of heart and lung capacity a man will be 
better off if spare than if corpulent ; because in the latter case he has 
an additional load to carry, and has to nourish and keep up a thick 
blanket of fat from which he derives no adequate advantage. Hence a 
person of spare build who survives childhood and adolescence without 
disease probably has on the whole a better prospect for long life than a 
stout person. 

Normal Habit. In estimating the size or weight of the patient it is 
important to ascertain the customary habit of the individual as to the 
taking on of flesh, and if it developed suddenly or followed acute disease. 

Weight. Nothing has yet been said of the weight, but as it affords a 
precise estimation of the size, particularly if considered in relation to 
the height and age, the following discussion will include the two points, 
size and weight. 

While the weight of the body can be estimated approximately by the 
eye and the degree of emaciation noted, the habit should be formed of 
accurately estimating it by means of the scales. Machines are now 
made which can be used for weighing the patient and at the same time 
noting the exact height. It is particularly important to note the weight 
from time to time. In the course of wasting disease we learn the effects 
of treatment thereby, or, on the other hand, the march of disease in 
spite of treatment. In obscure cases, as of tuberculosis, persistent loss 
of flesh is a serious diagnostic and prognostic symptom. After acute 
disease, if the patient is weighed every week, the onset of insidious 
sequelae, as tuberculosis, may be detected. 

The relation of body weight to height is of importance. It is also 



64 



GENERAL DIAGNOSIS. 



important to have knowledge of the average weight of the individual 
in different periods of life. The progressive increase in weight which 
should take place after birth should be remembered, as the opposite is 
positive evidence of malnutrition. 

The table of Mr. Hutchinson is sufficient to enable us to judge the 
average weight of a man of a given height in health : 

A man of 4 ft. 6 in. to 5 ft. 0 in. ought to weigh about 92.26 lbs. 

" 5 " 0 " 5 " 1 " " " 115.52 " 

5 " .2 " 5 " 3 " " " 127.86 " 

5 " 4 " 5 " 5 " " " 139.17 " 

5 " 6 " 5 " 7 " " " 144.29 " 

5 " 8 " 5 " 9 " " " 157.76 " 

" 5 " 10 " 5 " 11 " " " 170.86 " 

5 " 11 " 6 " 0 " " " 177.25 " 

In some life-insurance tables of this country the average weight for 
the height is lower, especially in persons over five feet ten inches. 

Local Weight. It is not to be forgotten that accumulations of fat 
may take place in special portions of the body ; the abdomen is the 
favorite seat for excessive accumulation, particularly in womeu and in 
men of sedentary life with habits of excessive indulgence in food and 
drink. 

Weight in Disease. The question of weight is an important one in 
disease. As has been stated, persons with an excess of fat do not bear 
fevers and exhausting processes so well as those w^ho have a larger pro- 
portion of firm muscles in proportion to their weight. Remember, if 
emaciation is present, to ascertain its amount and degree, its relation to 
unusual mental care, or to acute disease. Slow T progressive emaciation is 
of serious moment, as evidence of tuberculosis or disorder of assimila- 
tion. Remember the wasting that is associated with great hunger, 
excessive thirst, and polyuria in diabetes. On the other hand, such 
symptoms as occasional cough, slight evening fever aud impairment of 
resonance at one apex of the lung, become much more significant of 
incipient phthisis if accompanied by loss of weight. And at any stage 
of phthisis a maintenance of the body weight is one of the most favor- 
able elements in prognosis. 

Again, while loss of weight attends all the diseases of the digestive 
tract which interfere seriously with nutrition, it progresses more rapidly 
and steadily and attains a greater degree in malignant disease than in 
the mechanical or functional diseases. Hence the question of loss of 
weight is important in deciding between chronic catarrhal gastritis and 
gastric carcinoma. But still more important is the question of the 
time during which loss of flesh has been taking place, and whether it 
has been progressive or interrupted by periods of gain in weight. If 
during two or three years the patient has been vomiting occasionally 
and losing flesh, but gaining again from time to time, it is much more 
significant of gastric catarrh than of gastric cancer. 

False Increase of Weight. In certain cases of great anasarca and in 
malignaut disease of the abdomen, especially huge cysts of the ovary 
in women, and sarcoma of the kidney in children, there may be actual 
increase of weight due to the accumulation of water or to the new 
growth, though the rest of the body is manifestly emaciated. 

Weight in Children. In babies and children fat is more likely to be 



THE DATA OBTAINED BY OBSERVATION. 



65 



a sign of good health than in adults. Nevertheless, the quality of the 
flesh is to be taken into consideration. There are fat and flabby 
babies and children, and there are others who are fat but whose flesh 
has a firm, solid feel. The former often gain and lose flesh rapidly, and 
when ill do not appear to have much resisting power. The size of a 
child gives a good idea of its nutrition. A child may have its growth 
stunted by bad food and unfavorable hygienic conditions, or the stuut- 
ing may be the result of exhausting disease, such as whooping-cough. 

Degree of loss. The whole body may exhibit considerable loss of flesh, 
the cheek bones and temporal fossae being distinctly visible, the muscles 
soft, the limbs wasted, and the subcutaneous fat diminished. It is 
important to notice whether flesh has been lost or not, and how much, 
and how long a time the loss has been going on. Such facts furnish the 
clue, not only to diagnosis but to treatment also. Flesh is lost in almost 
all the acute and chronic diseases, but it becomes of special moment in 
diagnosis in the latter. It is most noticeable in tuberculosis, cancer, 
marasmus, cirrhosis of liver and kidneys, diabetes, in anaemias, and in 
cachectic conditions due to prolonged suppuration or chronic diarrhoea. 

Local Change in Size. There may be local increase or diminu- 
tion in size, alone or combined. When one part is increased in size and 
another growing progressively small, the incongruity indicates disease 
(see below). The face is swollen, especially under the eyes and above 
the jaws, in the dropsy of large white kidney and in parotitis. The 
neck may be enlarged in the sterno-clavicular notch, or laterally above 
the clavicles in aneurism. The thyroid as a whole, or both lobes, is 
enlarged in goitrous affections and in Graves' disease. 

The face may be thin and even much emaciated while the abdomen is 
greatly distended from dropsy or from tumors of the various abdomi- 
nal viscera or glands. The chest is enlarged or contracted. Local 
increase in size in thorax or abdomen is significant of tumors. 

The head is much increased in size in chronic hydrocephalus, while 
the face remains small. 

The loss in flesh in the extremities or special muscles may be local 
and atrophic in character, as in some diseases of the nervous system, 
such as neuritis, infantile palsy, hemiplegia, and monoplegia. 

The increase in size may also be local, as in hydrocephalus, elephan- 
tiasis, myxoedema, oedema, and various tumors. 

Changes in the Skeleton. The degree of development, the 
size and the strength of the individual in general, may be ascertained 
by the condition of the bones of the skeleton. 

Enlargement of the Bones. In some affections the bones are unduly 
enlarged, modifying the general form and causing increase in the size of 
the individual. 

Acromegalia. Marie first described acromegaly, a remarkable change 
in the skeleton, in which the bones of the hands, feet, and face are 
particularly the seat of hypertrophy. The fibro-cartilages of the ear 
and larynx also enlarge. The enlargement of the inferior maxillary and 
frontal bones causes the face to assume a peculiar, elongated, elliptical 
outline. The nasal bones are enlarged, and the nose thickened ; the 
temporal fossae are deepened on account of enlargement of the malar 



66 



GENERAL DIAGNOSIS. 



bones. The forehead retreats because of the enlargement of the frontal 
sinuses and projection of the superciliary ridges ; the chin is promi- 
nent aud the lower teeth project beyond the plane of the upper; the 
lips and eyelids may be thickened ; the tongue is enlarged aud thickened ; 
the hands present a peculiar appearance ; they are much broader, the 
terminal phalanges are flattened and give the hand a spade-like shape ; 
the nails present longitudinal striations. With the changes in the face 
and hands there is usually spinal curvature ; the abdomen is prominent, 
and, as before intimated, the height is increased. The muscles become 
weak and may atrophy ; the skin is often pigmented, varicose veius 
have been observed, and the patient complains of hemorrhoids. The 
thyroid gland may be atrophied or hypertrophied. It may be well to 
state in passing that with these appearances nervous phenomena are 
observed and disorder of special senses complained of. Hemianopsia, 
limitation of the visual field, and blindness or deafness arise. 

Osteitis deformans. Another remarkable change is seen in the skele- 
ton and has been described by Sir James Paget; in this there is marked 
change in the contour of the patient aud a peculiarity in the mode 
of locomotion. It is known as osteitis deformans. The head is ad- 
vanced and lowered, so that the neck is very short, and the chin, when 



0 


Fig. 1. 


0 


i 


0 


3 


Outline of face in 


Outline in acro- 


Outline in osteitis 


myxoedema. 


megaly. 


deformans. 



the head is at ease, is more than an inch below the top of the sternum. 
The chest becomes contracted, narrow, flattened laterally, deep from 
before backward, aud the movements of the ribs aud spine are lessened ; 
the arms appear unnaturally long, the shafts of the tibia and femur are 
bent so that the patient becomes bow-legged. There is some stiffness, 
but no loss of power and not a great deal of pain. The skull is in- 
creased considerably in thickness. These changes in the bones cause a 
dwarfed appearance of the trunk in comparison with the legs and arms, 
and the posterior lateral curvature necessitates a characteristic attitude. 
The skeletal changes are noted particularly in the long bones. As a result 
of the enlargement of the cranial bones, the face presents a triangular 
outline, with the base above and the apex below (see Fig. 1, outline 3), 
thus differing in appearance from the outline in acromegalia. (Fig. 1, 
outline 2.) 

Pulmonary osteo-arthropathy. Marie distinguishes acromegaly from 
another skeletal change in which there is hypertrophy of the bones of 
the extremities and the shafts. In this form of arthropathy the bones 
of the head and face are not affected. The hands and feet are enlarged, 
and the patella? and other bones of the knee-joints increased in size. 



THE DATA OBTAINED BY OBSERVATION. 



67 



Curvature of the spiue is present. The appearance of the fingers is 
different from those of acromegalia. The ends are enlarged and bulbous 
and the nails curved in a transverse and longitudinal direction, like the 
clubbed fingers of phthisis, although the chief enlargement of the fin- 
gers is not terminal, and there is no cyanosis as in phthisical clubbing. 
The change seemed to be associated with pulmonary affections, and 
Marie applied to it the name osteo-arthropathie pneumonigue. 

Local changes of the bones are considered in the section on local 
examination of the exterior. 



Fig. 2. 




Pulmonary osteoarthropathy. Female, aged eleven. Tuberculous vertebral caries 
and pulmonary tuberculosis. 

Diminution in Size. Small development of the bones is seen in 
idiots aud cretins. 

Mhachitis. In this affection the size of the body is lessened. For 
its distinction it is important to know how rapidly the osseous deposits 
in childhood have formed. The fontanelles and the epiphyses must be 
examined. If the fontanelles are open beyond their period of closure 
in health, or if the epiphyses are enlarged and lack firmness, the condi- 
tion points either to simple malnutrition or to an affection of the bone 
known as rhachitis. In rhachitis late development of the teeth is ob- 
served. If at the same time the ribs are examined, nodules will be 
detected at the junction of the bone with the cartilage. These may be 
seen, as well as felt, if the child is thin. They form the so-called 
rhachitic rosary. The thorax also is changed in shape. At the junction 
of the cartilages and ribs a depression takes place which is continuous 



68 



GENERAL DIAGNOSIS. 



with a groove which passes out from the ensiform cartilage toward 
the axilla. This transverse carve is known as Harrison's groove. 
It may deepen with inspiration. At the same time the sternum pro- 
jects, forming the so-called " pigeon-breast" (see Thorax). On exami- 
nation of the long bones changes are noticed at the lower end of the 
radius and ulna, and sometimes at the end of the humerus. The parts 
are enlarged at the junction of the shaft and epiphyses. There may be 
thickening of the clavicles at the sternal ends. In the legs the lower 
end of the tibia becomes enlarged, and at times the upper end, or even 
the shaft, becomes thickened. The child becomes bow-legged, or the 
tibiae and femora may arch forward. Knock-knee sometimes occurs. 
The bones of the vertebral column and of the pelvis are also affected. 
The spine is usually curved posteriorly, but lateral curvature may also 
be produced with it. The contraction of the pelvis is such as to narrow 
its outlet — a matter of much importance for the future of female children. 

The head of the child with rickets is quite characteristic. It has been 
mentioned that the fontanelles remain open for a long time, and areas 
of ossification are imperfect, so that the bone yields to the pressure of 
the finger. This occurs particularly at the side, and the term cranio- 
tabes is applied to it. The large head is square in shape when looking 
over it from above downwards. It gives to the face a peculiar appear- 
ance. It is proportionately very small, especially in the lower two- 
thirds, while the forehead is broad and square. 

The condition is not difficult of recognition if the general and local 
appearances just indicated, associated with the symptoms of the disease 
(see Rhachitis), are coupled together. 

Osteomalacia. Among the general affections of the skeleton, which 
may cause lessened size, osteomalacia must not be forgotten. As the 
lime salts are dissolved, the bones become preter naturally soft, break on 
the slightest provocation, or bend in various directions, depending upon 
the external pressure and the direction of the muscular force. The ribs 
are drawn in by inspiratory forces until the cavity of the thorax is 
lessened to a degree incompatible with life. The pelvis is deformed so 
that labor is impossible. (It occurs frequently in pregnancy.) All sorts 
of fixed contortions are assumed. If able to be up, the body shortens, 
the back becomes rounded, the neck stooping so that the chin is brought 
close to the sternum. On palpation, the bones can be indented by the 
finger, and crepitate like eggshells. 

Osteomalacia is easily distinguished from carcinoma or sarcoma of 
the bones. In the latter spontaneous fracture occurs in various parts of 
the skeleton, but is generally preceded by pain and swelling at the seat 
of fracture. Then, in sarcoma subcutaneous hemorrhages are present. 
When one joint is affected, osteo- sarcoma, the same eggshell crackling 
is observed. 

6. The Exterior in General. The Skin. The external examina- 
tion reveals the color of the skin, its tone, the degree of moisture, the 
presence of eruptions, of hemorrhages, and of scars. The temperature 
is also observed. 

The Hue and Color. The portions exposed to the air exhibit 
more varied and pronounced changes of color than parts that are cov- 



THE DATA OBTAINED BY OBSERVATION. 



69 



ered. It is understood that the changes in color herein described refer 
more particularly to the face and hands, and that the color of other parts 
partakes of the same tint as that of the face, other things being equal, 
except that the intensity is less. Comparison of the two should always 
be made, and the mucous membranes examined, as control experiments. 
For the latter, the conjunctivae, lips and mouth are sufficient, always 
remembering the possibility of hyperemia of the conjunctiva from 
other causes. 

Local change of the face will be particularized in this section. It is not 
to be forgotten that the color varies with the type, whether blonde or 
brunette, and that variations in the latter at times easily escape recogni- 
tion. 

The skin in a healthy child is of a faint pink color ; as age advances 
it loses its fresh appearance and becomes paler, except in those whose 
occupation exposes them to atmospheric influences. In the latter the 
skin becomes weather-stained, and may assume a mahogany or reddish- 
brown hue. In old age the color is apt to deepen and become duller, 
while the loss of subcutaneous fat allows the skin to lay in folds, espe- 
cially about the jaws and neck, and wrinkles are marked, especially 
between the eyebrows, over the nose, and at the angles of the eyes and 
mouth . 

Apart from these changes, which are physiological or those necessarily 
the result of occupation, the skin exhibits changes the result of the 
habits or health of the individual. Some persons, especially if blondes, 
retain to old age the fresh, clean, pink skin of childhood. In others is 
seen early a dull, muddy complexion. This is common in those who 
use coffee to excess aud are of constipated habit. In others, digestive 
derangements, particularly constipation, produce in addition to a muddy 
complexion, crops of acne and comedones or black-heads. It must be 
admitted, however, that some persons preserve a fresh complexion in 
spite of marked digestive disturbance. Considerable congestion of the 
superficial bloodvessels, giving the person a florid appearance, may be 
due, especially in a young person, to alcoholic excesses ; and there is a 
popular belief which connects such an appearance, when coupled with a 
tuberous nose and a crop of angry-looking pustules, with a prolonged 
use of spirits. 

Color Increased. The abnormally red skin. Physiological hyper- 
emia has been spoken of. The color is intensified when the capillaries 
are overfilled, or the blood current is unusually rapid. The hyperemia 
may be general or local, and is due to dilatation of the capillaries, pos- 
sibly from nerve influences. G-eneral hyperemia is seen in fever and 
in poisoniug from atropine. It is the glow that the warm bath and 
external friction excite. Local hyperemia attends the phenomena of 
blushing and comes and goes in nervous persons, with every psychical im- 
pression. Abnormal redness may be diffused over the whole face or may 
present the circumscribed flush of phthisis ; the local deep-red area, on 
one cheek, of pneumonia ; the evanescent flush of anaemia, with cardiac 
palpitation ; and the creeping flush, with raised border, of erysipelas, ap- 
pearing on the bridge of the nose or at the nostril. In phthisis small 
excitement or exertion, taking food, or the onset of fever, tinges the cheek 



' 70 



GENERAL DIAGNOSIS. 



with the blush of hectic. In migraine, the burning flush may be 
limited to oue side. Capillary congestion on the cheeks or tips of the 
nose occur with the endarteritis of the aged, but is seen also in earlier 
life in cases of hepatic cirrhosis, or obstruction to the hepatic circulation 
from other causes. 

Color Lessened. Pallor. It is caused by diminution in the 
amount of blood in the capillaries, or because the richness of the blood 
in haemoglobin has been reduced. 

Diminished amount of blood in the capillaries occurs from active 
contraction or spasm of the arterioles, from hemorrhage, or from weak 
heart. The pallor that arises, therefore, is usually acute or temporary, 
and may be recurrent. It results from fright, syncope, or nausea and 
vomiting. It occurs also in acute poisoning, in acute diseases, such as 
diphtheria, and in hemorrhage. The pallor that arises from hemorrhage 
comes on more gradually, that is, iu the course of an hour or more, or 
during three or four days. Of course, if the hemorrhage is excessive 
the pallor may come on in a few minutes. Sudden pallor in the course 
of diseases which may be attended by hemorrhage, is of diagnostic sig- 
nificance, as in the course of aneurism, gastric or intestinal ulcer, and 
the ulceration of typhoid fever. With the onset of the pallor, if due to 
hemorrhage, the symptoms of collapse are seen. 

Pallor of long duration, or chronic pallor, if we may so term it, is 
seen in a number of diseases. In all of them there is diminution in 
the amount of red corpuscles, and destruction of the haemoglobin. It 
is characteristic of blood affections, as the forms of anaemia and leuco- 
cythaemia. It is seen in striking form in chronic Bright' s disease, in 
cancer, in chronic poisoning, as from lead or arsenic, in chronic catarrh 
of the stomach or of the bowels, and in chronic infectious processes, as 
tuberculosis and syphilis. 

While paleness is recognized as the fundamental or prevailing color 
of the skin in many of the above-noted affections, a further tinge gives 
a characteristic hue to the skin ; thus in chlorosis there is a greenish 
appearance of the face, which is in striking contrast to the pearly colored 
conjunctivae. In carcinoma, the yellowish tinge to the pallor often 
causes it to be mistaken for jaundice. In pernicious anosmia, a straw- 
colored appearance of the skin has been frequently described on account of 
which cases have been thought to be due to carcinoma. It is worthy of 
remark that the cachectic pallor in carcinoma is not likely to occur 
unless there are primary or secondary deposits in the gastro-intestinal 
tract or the liver, and it is well known that pernicious anaemia is 
usually secondary to gastric or hepatic disorder. The peculiar hue of the 
pallor, therefore, may have a common cause in these affections. The 
pallor that attends BrigMs disease is usually associated with slight 
puffiness under the eyelids or local dropsical accumulations elsewhere. 
In chronic poisoning with lead, pallor is associated with a blue line 
upon the gums, and drop-wrist; while in arsenical poisoning there is 
frequently associated a puffiness of the eyelids and looseness of the 
bowels. 

It is not well to lay much stress upon the variations in hue of the 
pallor. They are not of diagnostic importance in themselves, but only 



THE DATA OBTAINED BY OBSERVATION. 



71 



when associated with the characteristic symptoms and signs of the re- 
spective affections in which this hue occurs. 

It must not be forgotten that there are a large number of individuals 
in whom pallor is the normal condition. This is particularly the case 
with those who lead a sedentary life, and are confined within doors. 
There are a number of occupations which predispose to pallor. 

Jaundice. Jaundice is a symptom due to a number of diseases. 
In the first place it is most frequently due to disease of the liver, 
and this variety is known as hepatogenous jaundice. It may also be 
due to destruction of the corpuscles of the blood and liberation of 
the haemoglobin, and then is known as haematogenous jaundice. 
The various causes of the former will be considered under diseases 
of the liver. The latter form is due to destructive agencies in 
the blood, such as ptomaines, which are absorbed in gastro-intestinal 
disease, or poisons that develop in the course of pyaemia, yellow fever, 
malarial and relapsing fevers; it may also be due to snake-bite or to 
poisons that are imported, as in mineral poisonings. 

In both instances, the yellow coloration of the skin is due to color- 
ing matter of the bile in the blood, or bilirubin, which is deposited in 
the cells of the rete mucosum. The yellow coloration is seen not only 
in the skin, but in the conjunctivae and other mucous membranes. 
The discoloration of the skin is not difficult of recognition. It 
varies iu shades from a slight yellow hue to yellow-green, and in 
many forms of jaundice to brownish-yellow. The yellow hue of 
the skin in jaundice may be preceded by tinging of the conjunctivae, and 
if the former is doubtful, it can be corroborated by the appearance of 
the mucous membrane. The mucous membrane under the tongue early 
gives evidence of jaundice. Or if the lips are everted and a glass slide 
pressed evenly on the surface, the yellow discoloration of the mucous 
membrane will shine through. 

The yellow tint of the conjunctivae must not be confounded with the 
same color due to sub-conjunctival fat. The latter is not uniform in 
the conjunctivae, and may be seen to occupy cone-shaped areas. 

The physiological yellow color of the skin that is seen in infants 
shortly after birth is not a true jaundice, but in all probability arises 
from excessive destruction of red corpuscles in the over-congested skin. 
On light pressure with the finger the color changes. It fades from 
shades of yellow into the genuine flesh-color. The conjunctivae are 
natural, and the urine is free from bile pigment. The faeces are 
normal. By these symptoms a distinction can be made. 

While jaundice is a symptom, it is nevertheless the cause of many 
symptoms, the presence of which may be of diagnostic value in deter- 
mining the nature of the yellow color of the skin in cases of doubt. 
The yellow coloration of the conjunctivae and the mucous membranes 
has been mentioned. (1) Itching. In addition, the surface of the 
body is often seen to be covered with scratch-marks, due to itching, 
caused by irritation of the peripheral ends of the nerves in the skin by 
bile pigment. (2) Slow pulse. Slowness of the pulse also frequently 
attends jaundice. The coloring matter invades the fluids of the body 
and is carried off by the kidneys. (3) Secretions and excretions. The 



72 



GENERAL DIAGNOSIS. 



saliva, or expectoration if present, is bile-tinged and the urine is dark- 
colored, due to the presence of the pigment. (See Urine.) While the 
excretions are all tinged with bile in the hepatogenous form, the faeces 
are free from bile, hence they are pale or of an ashy color. On account 
of the absence of bile in the intestines its physiological purposes are 
lost, and therefore flatulency from fermentation becomes an important 
symptom. 

Cyanosis. This peculiar hue is recognized without difficulty. The 
bluish or bluish-red appearance of the skin is first seen at points farthest 
from the central organ of circulation, as in the extremities. The mucous 
membranes, in which the capillary circulation is readily seen, also ex- 
hibit the change early. Hence the blueness of finger-tips, particularly 
underneath the nails, the bluish discoloration about the phalangeal 
joints, and the blue lips of the early stage of cyanosis. Thence the entire 
surface of the skin may become dusky or cyanosed as its cause in- 
creases in degree. It is not difficult of recognition. Its onset, it is said, 
can be anticipated by the state of the veins on the under part of the 
tongue ; overfilling or extreme distention of these vessels always occurs 
in cyanosis. The color usually disappears on pressure at first wherever 
situated, but as the hue deepens it will remain in spite of pressure. 

Causes. Cyanosis is due (1) to overfilling of the veins and capil- 
laries with blood not sufficiently oxygenated, or (2) to an excess of 
venous blood, oxygenation not being interferred with. 

1. All conditions which interfere with the aeration of the blood lead 
to the development of cyanosis. Obstruction of the air-passages, or 
encroachment upon the extent of respiratory capacity, or interference 
with the circulation in the lungs, will cause this condition. 

a. Obstruction of the air-passages. This may occur in the upper 
respiratory tract, or in the capillary bronchi. Faucial obstruction, on 
account of abscess or tonsillitis, or in rare cases diphtheria, causes 
moderate cyanosis. Affections of the larynx which cause obstruction, 
produce cyanosis varying in degree with the amount of obstruction and 
its persistence. The cyanosis is of short duration in spasmodic croup, 
and in laryngismus stridulus ; it is prolonged in the more persistent 
inflammatory affections. Its onset, in moderate degree, as seen by the 
purple lips or dusky finger-tips, is of serious prognostic import in the 
course of tuberculous laryngitis, even if symptoms of grave obstruction 
have not arisen. Tumors, pressing on the trachea or bronchi, narrow- 
ing the air channel, cause cyanosis. The tumors may be situated in the 
neck, as the thyroid gland, or within the mediastinum. Spasm of the 
bronchi, as in asthma, occlusion of the bronchioles, as in bronchitis, 
both acute and chronic, and particularly the grave form of capillary 
bronchitis seen in childhood, cause cyanosis. 

It must not be forgotten that foreign bodies anywhere in the course 
of the respiratory tract in its upper regions are fruitful sources of 
cyanosis. 

b. In encroachments upon the normal air-space, such as take place in 
pneumonia, in oedema of the lungs, in tuberculosis, in all forms of 
pleural effusion compressing the lung, and in conditions beyond the 
thorax which interfere with expansion, lead to the development of 



THE DATA OBTAINED BY OBSERVATION. 



73 



cyanosis. Deficient expansion, and therefore lessened respiratory area, is 
of commou occurrence in affections which interfere with the action of 
the respiratory muscles. This interference may be either on account 
of paralysis or on account of pain, or, in the case of the diaphragm, 
on account of pressure from fluids or accumulations in the abdominal 
cavity underneath. Large peritoneal effusions, and abdomiual disease, 
causing enlargement with upward pressure of the diaphragm, produce it. 
In bulbar paralysis and peripheral neuritis, in paralysis of the dia- 
phragm, in spasm of the muscles of respiration, as in tetanus, it is seen. 
In forms of progressive muscular atrophy cyanosis is also observed, and 
in other rare affections of the muscles, as trichinosis. 

c. Interference with the circulation within the lungs, from pressure 
on the bloodvessels, pulmonary artery or vein, or from diseases of the 
heart itself, is a most irequent cause of cyanosis. In affections of the 
heart it is not seen until, in the case of valvular disease for instance, 
compensation is lost and the blood is accumulated in the lungs on ac- 
count of dilatation of the right heart. It is seen that in the latter, both 
conditions are combined and contribute to the cause of the cyanosis ; 
that is to say, in affections of the heart or obstruction of the pulmonary 
vessels, the congestion of the lungs that ensues is also associated with 
more or less obstruction of the bronchi on account of collateral conges- 
tion and catarrh. 

2. Obstruction to the flow of blood anywhere in the circulation will 
lead to the development of cyanosis. This is the cyanosis of passive 
congestion. Cyanosis originating from causes mentioned above is 
always general. Cyanosis that develops from causes which will be 
indicated in this section may be general or local, depending upon the 
seat of obstruction. If the heart is diseased and there is interference 
with the flow of blood through the aortic side of the circulation, on 
account of obstruction or regurgitation at orifices, the venous side be- 
comes overdistended with blood. This form of cyanosis is typically 
seen in congenital heart disease. It occurs in valvular insufficiency, in 
disease of the heart muscle, aud in pericardial exudation. The develop- 
ment of cyanosis in valvular heart disease always implies failure of 
compensation and dilatation of the organ. 

Local cyanosis is seen in all cases in which there is obstruction of the 
venous trunks from external pressure, or from diseases of the venous 
wall causing thrombosis. It may be limited to the head and upper 
extremities in obstruction of the descending cava by tumor or aneurism, 
or to the lower portion of the trunk and extremities by obstruction of 
the ascending cava from tumors within the abdomen and thorax pressing 
upon it. One extremity may be the seat of local venous stasis from 
pressure upon the vein or its occlusion by thrombosis : the arm in cases 
of cancer of the breast and axillary glands, the leg in cases of femoral 
phlebitis, represent typical forms of venous stasis. (See under Fingers, 
Raynaud's Disease.) 

The Bronzed Skin. The most marked form of bronzing is seen 
in Addison's disease. The external surfaces are changed in hue, and 
delicate portions of the skin underneath the clothing are also bronzed. 
The discoloration is not removed by pressure. The areas are irregular 



74 



GENERAL DIAGNOSIS. 



in shape. The skin is soft and pliable. The pigment which causes the 
discoloration is deposited in the rete Malpighii. 

The pigmentation is never seen in the cornea or in the nails. The 
axilla, the flexures of joints, the median line, the areola about the 
nipple and other normal areas of pigment deposit are the seat of this 
deposition of pigment. In the mucous membranes the bronzed areas 
are limited to patches ; they are sharply circumscribed brown areas 
seen in the mucous membrane of the lips and cheeks. 

The discoloration of the skin in Addison's disease must not be con- 
founded with a similar discoloration that occurs on account of sunburn. 
The discoloration under the latter circumstances is limited to parts that 
are exposed to the sun, is more uniform, and the mucous membranes 
are free. Moreover, the anaemia and debility of Addison's disease do 
not attend it. 

In persons living in filth a general discoloration of the skin takes 
place, known as " vagabond's disease ;" but because it is so general and 
the skin is rough and thickened, and other evidences of filth are seen, 
it can easily be recognized. In the later stages of jaundice the dark- 
green or black hue of the skin might be taken for the general bronzing 
of Addison's disease. The appearance of the conjunctiva is sufficient 
to indicate the cause of the bronzing. In certain cases of tuberculous 
peritonitis, even if the capsule is not involved, the peculiar brown 
discoloration which simulates Addison's disease is present. 

Uterine Chloasma. The pigmentation that occurs in uterine disease 
or in pregnancy frequently resembles the bronzing of Addison's disease. 
It is usually confined to the forehead and cheeks and the normal pig- 
mentary areas of the skin. The mucous membranes are not affected, 
although in pregnancy there may be the characteristic change of the 
vaginal mucous membrane. In both, the general conditions that attend 
disease of the supra-renal capsule are absent. 

The bronzing of Addison's disease, the pigmentation of " vaga- 
bond's disease" and of pregnancy must not be confounded with the 
discoloration — yellowish-brown in hue — of tinea versicolor, a para- 
sitic skin disease. The latter is recognized by its color and irregular 
dissemination. It especially occupies the chest and spreads to the 
abdomen. It rarely ascends above the neck. It does not usually, there- 
fore, occur in parts exposed to the air, or in parts that are the seat of 
normal pigmentation. Then again, the surface desquamates in brownish 
scales. Examination of the scales put in a drop of dilute liquor 
potassee under the microscope show both spores and mycelium. The 
spores are of the fungus microsporon furfur. 

It must not be forgotten that there are cases of Addison's disease 
without the occurrence of the peculiar bronzing. The disease of the 
supra-renal capsule which is most frequently attended by the discolora- 
tion is tuberculosis. At times, the bronzing and other characteristic 
symptoms of the disease are associated with tuberculosis in other organs. 
Conversely, in cases of phthisis in which there is bronzing tuberculous 
disease of the supra-renal capsules may be suspected, and it adds to the 
gravity of the prognosis. 

Argyria. If nitrate of silver is administered over a long period of 



THE DATA OBTAINED BY OBSERVATION. 



75 



time fine black particles of the metal or of the albuminate are deposited 
in the kidneys, the intestine, and the skin. The corium is the principal 
seat of the deposition. The discoloration of the skin is gray or grayish- 
black. It is not changed by pressure, aud is usually limited to the face 
and hauds. Small specks may also be noted in the mucous membrane 
of the mouth. The cornea and nails are not affected. Persons are 
generally in good health, although the presence of the skin-change if 
seen in a patient with coma would point to the possible presence of 
epilepsy on account of which the drug had been taken. 

Freckles. Freckles are not usually of special diagnostic significance. 
Their occurrence iu an unusual degree has been observed, however, in 
cases of rheumatoid arthritis. Other signs and symptoms help to com- 
plete the picture of the disease. 

The Nutrition of the Skin. The color, as previously indicated, 
is a fair index of the nutrition of the skin, but in addition to this pal- 
pation gives further information. In health the skin is smooth, firm, 
and elastic. When pinched between the thumb and fingers and then 
allowed to escape it slips quickly back into its former position. When 
pressed or squeezed it becomes pale from expression of blood, but 
resumes it natural hue immediately. 

The readiness with which the blood returns after pressure gives infor- 
mation as to the character of the capillary circulation of the skin. 
This is active in health and sluggish in serious disease of the lungs, 
heart, and bloodvessels. In the eruptive fevers, especially in measles, 
scarlet fever and smallpox, sluggish capillary circulation with dusky 
eruption is a grave sign. In measles it is usually due to pulmonary 
complications, and in other infectious diseases to the overwhelming 
effects of the poisoning. 

As age advances the skin becomes less elastic, and in old persons may 
lie in wrinkles. When pinched between the fingers the skin is more 
inclined to remain wrinkled. Fat persons whose skin is firm and hard 
are in much better condition than those whose skin is loose and flabby. 
The latter condition is frequently met with in babies, particularly those 
that are fed on artificial foods. When the skin is thin and dry and 
loses its tone, so that when pinched into folds it resumes its smoothness 
but slowly and sluggishly, it is usually evidence, in a person under fifty, 
of some grave cachexia, as carcinoma. 

Moisture and Dryness of the Skin. Moisture and dryness are 
estimated with the tone of the skin, and in one sense are correlated. 
It is quite certain that when a skin is abnormally dry its nutrition is* 
impaired. 

In health the skin is not perceptibly moist, except as the result of 
physical exertion or under heat, or as the immediate result of imbibing 
a hot fluid or a sudorific drug. There is considerable individual 
difference, however, within the limits of the normal. Rheumatic and 
strumous persons may have a perceptibly moist and oily skin at all 
times, while others have a skin which perspires very little, even under 
influences which usually bring about perspiration. 

Perspiration Increased. The term hyperidrosis is applied to this 
condition. It may be general or local. A. General sweating is seen 



76 



GENERAL DIAGNOSIS. 



with normal or increased temperature. It occurs in the course of 
rheumatism, when the sweats are strong in odor and acid in reaction. 
It is seen in tuberculosis, especially the miliary variety. It is some- 
times marked throughout cases of typhoid fever. General perspira- 
tion also attends the violent muscular action of tetanus, but is not seen 
iu epilepsy. An example of general sweating is seen in that curious 
affection to which the term " sweating sickness" has been applied. It 
is a fever the nature of which is not well known, but in which this 
symptom is most pronounced. Sweating is extreme in trichinosis. 

B. With subnormal or normal temperature. 1. Sudden, temporary 
perspiration. Sweats are seen in patients who are weak during the stage 
of convalescence from acute disease. In this period of disease sweats 
may occur suddenly, from a fright or shock, which under other cir- 
cumstances would not influence them. General increase of perspiration 
may be of short duration and occur suddenly after fright or shock. It 
is the characteristic perspiration of collapse. The forehead is covered 
with sweat, large drops stand out on the face, the hands and feet are 
moist or wet with perspiration, and the whole surface of the body 
" leaks." In collapse that attends shock of all kind, or that occurs 
after hemorrhage or profuse discharge, as in cholera, this form of per- 
spiration is seen. It is attended with a cold and clammy skin. 

More striking still are the perspirations that suddenly break out in 
the course of acute disease, followed by a fall of temperature. We 
have (a) the critical sweats of pneumonia and relapsing fever ; (b) 
sweat which terminates a paroxysm of intermittent fever ; (c) the pro- 
fuse perspiration that attends pyaemia, breaking out with each fall of 
temperature to disappear as it rises ; (d) the night-sweats that attend 
tuberculosis and other exhausting diseases. In tuberculosis, or when 
there is pus-formation, the oscillation of temperature, with or without 
chills, followed by the sweating, is known as hectic. Sudden breaking 
out of perspiration, general, but more notably seen on the face, attends 
dyspnoea of pulmonary origin and the attacks of dyspnoea in the 
course of organic heart disease. These perspirations are at times the 
result of an effort at elimination, on the part of the skin, to relieve the 
kidneys or bowels, such as the perspiration of uraemia, which is attended 
by a urinous odor. At times in jaundice it may also occur. 

In the conditions just mentioned there is coolness of the skin, and 
especially of the extremities. 

2. Prolonged Perspiration. In exhausting diseases general persistent 
perspiration may occur, particularly in the later stages, as in tuberculosis, 
and in any disease attended by persistent dyspnoea. 

Local increased perspiration (hyperidrosis localis) occurs when there 
is local vasomotor paresis. Thus, in organic diseases of the brain and 
in affections of the peripheral nerves, in some forms of neuralgia, it has 
been observed, and in migraine with hysteria. Sometimes one side of the 
body alone is affected, even in a malarial paroxysm (hemidrosis). Uni- 
lateral sweating of the head arises from pressure on the sympathetic 
nerves in thoracic aneurism. 

Local sweats are sometimes significant. This is the case particularly 
with a sweat confined to the head, which occurs usually in children, and 



THE DATA OBTAINED BY OBSERVATION. 77 



is one of the striking characteristics of rickets. With the local sweat- 
ing the patient rolls his head at night on account of the discomfort. 
The hair on the back of the head is seen to be rubbed off. 

Diminished Perspiration — Anidrosis. The skin is abnormally dry 
in the early stages of acute disease attended with fever, particularly 
if the febrile rise takes place suddenly, as in the acute digestive dis- 
orders of children. In adults when the disease is accompanied by high 
fever, as in thermic fever, the skin is dry. In the first day of the erup- 
tion of the exanthemata the dryness is marked. Dryness of the skin is 
of frequent occurrence when there are copious discharges of water from 
the bowels or the kidneys. In choleraic diarrhoea the dryness occurs 
suddenly. In some affections, as diabetes and Bright's disease, the dry- 
ness extends over a long period of time, and is frequently attended by 
eruptions or desquamations and by the formation of boils. When there 
are accumulations of serum in the lymph spaces of the subcutaneous 
connective tissue, or changes in the connective tissue, as in dystrophies 
or myxoedema, the skin is dry because of the stretching and pressure 
on the bloodvessels. 

Scars. Scars are important proofs of the occurrence of previous dis- 
ease, especially smallpox, chickenpox, and syphilis. Scars of the first 
two occur in the form of circular pits, and almost always on the face. 
Scars of syphilis are larger, circular or oval in shape, and seen usually 
to best advantage on the extremities, but the single scar on the forehead 
is strikingly suggestive. Scars upon the legs in persons under thirty 
years of age, when not traumatic, are almost always syphilitic. Scars 
as the result of suppurating glands are seen most frequently in the 
neck, but may be found wherever there are glands, especially under the 
jaw and in the axilla and groin. They are most liable to occur in tuber- 
culous persons, either spontaneously or as the result of the exanthemata, 
erysipelas, or other infectious disease. When such scars are met with in 
a person with incipient tuberculosis the prognosis becomes more anxious. 

The appearance of the scar indicates in a general way its age, and 
hence throws light upon the patient's previous history and also serves 
as a check upon the accuracy of his statements. 

Scars the result of wounds, injuries or operations may be seen 
anywhere ; they are of importance only so far as they may furnish a 
clue to the cause of existing disease. Of such nature are the scars upon 
the head in cases of brain disease, particularly epilepsy. 

The scars of pregnancy, the striae seen upon the lower part of the 
abdomen and the upper part of the thigh, must not be confounded with 
similar scars that occur in great oedema, and which are sometimes found 
in fat persons. 

Hemorrhages. Hemorrhages in the skin are called, according to 
their size, petechice, ecchymoses, vibices, and hcematomata. The petechia 
and ecchymoses are apt to appear in the hair follicles, and vary in size 
from a pin-point to a split pea. They must be distinguished from ery- 
thematous and other eruptions. 

Mode of Recognition. They may be raised above the surface of the 
skin ; they do not disappear upon pressure, and vary in hue from deep 
red to yellow-brown, according to their depth beneath the surface and 



78 GENERAL DIAGNOSIS. 

to the degree of absorption that has taken place since the hemorrhage 
occurred. 

Vierordt advises the following test to distinguish them from ery- 
themas : Press a piece of glass (a microscope slide) upou the suspected 
spot. A hemorrhage is rendered more distinct, while the surrounding 
part becomes more anaemic. An inflammatory hyperemia, on the other 
hand, disappears. 

Cause. They may be due to affections of the blood or disease of the 
bloodvessels. When they occur in the course of blood diseases it is 
because there has been such a change in the quality of the blood that dia- 
pedesis can take place more readily. They are more particularly, but 
no exclusively, seen in dependent parts, especially the lower extremities. 

Significance. While the recognition of subcutaneous hemorrhages 
is comparatively easy, their diagnostic significance must depend upon 
the phenomena with which they are associated, or upon their occurrence 
conjointly with hemorrhages from other organs. Moreover, the situa- 
tion of the hemorrhage is in a measure an index as to its causal origin ; 
thus hemorrhages about joints are purpuric or haemophilia 

1. Hemorrhage with Fever If subcutaneous hemorrhages are found 
in the course of acute disease with high temperature they may be 
dependent upon changes in the quality of the blood, or upon obstruc- 
tion of the bloodvessels with emboli. The former class are seen in 
cerebro-spinal fever, and in measles, variola and scarlatina. The cere- 
bral and spinal symptoms in the first affection point to its probable 
origin. In the exanthemata they develop with the characteristic erup- 
tion, although the latter may be darker in color than normal. Hemor- 
rhages will probably take place at the same time from the mucous 
membrane, hence the nares will be occluded and the mouth and fauces 
filled with clotted blood. In milder degree sordes collect in the mouth. 
They usually indicate malignancy in these affections. 

The latter class of hemorrhages are hemorrhagic infarcts and are seen in 
pyaemia and ulcerative endocarditis. The hemorrhages are small, some- 
times elevated, more abundant on the extremities, but distributed over 
the trunk ; they are seen as small areas in the mucous membranes, 
observed in the conjunctivae, and on ophthalmoscopic examination found 
in the retina. The association of chill, fever, and sweat, the presence of 
pus in some structures of the body, and the characteristic joint affections, 
point to pyaemia. On the other hand, if due to ulcerative endocarditis, 
the physical signs of this affection render the recognition of the cause of 
the hemorrhage clear. Finally, in fever with involvement of the joints, 
of rheumatic in contradistinction to pyaemic origin, we have the occur- 
rence of purpura. In the most marked degree it is seen as peliosis rheu- 
matica, and is associated with hemorrhages in other portions of the body. 

2. Hemorrhage with Ancemia. In all forms of anaemia attended by 
debility hemorrhages occur. In idiopathic or pernicious anaemia they 
are usually only small hemorrhages, but may become more extensive. 
They occur on the extremities, aud usually on the dorsum of the feet 
or hands. There may also be retinal hemorrhages. In the secondary 
anaemias that arise in the later stages of carcinoma with emaciation, 
particularly of the stomach, in the later stages of Bright' s disease, and 
of cirrhosis of the liver, they are also seen. 



THE DATA OBTAINED BY OBSERVATION. 



79 



Purpura Rheumatica. If the hemorrhages are limited to the legs, 
and particularly if found about the joints, and if they are compara- 
tively large, having the appearance of black-and-blue spots ranging 
from the size of a three-cent piece to a half-dollar, if there has been 
a history of rheumatism, or the patient complains of joint symptoms, 
they are usually of the nature either of rheumatic purpura or purpura 
hemorrhagica. Some forms of purpura, as peliosis rheumatica, are 
attributed to the presence of bacteria, and indeed, with scurvy included, 
are by some writers said to be infectious. The micro-organism, 
however, has not been isolated. Finally, reference must again be made 
to the subcutaneous hemorrhages which occur in sarcoma of the skin 
and bones, and in jaundice. In the latter atfection when malignant, 
the mucous membranes also bleed. The lips, gums, and tongue are 
covered with sordes. The conjunctiva is the seat of hemorrhage, and 
so also are other mucous membranes. 

Scurvy is an affection characterized by anaemia, debility, and wast- 
ing, in which there are hemorrhages under the skin as well as from the 
mucous surfaces. The gums are particularly affected. They bleed 
easily. Hemorrhages also occur in the deep lymphatic spaces, in the 
muscles, underneath the periosteum, and in the joints. 

3. Subcutaneous Hemorrhage with Hemorrhage Elsewhere. The 
diagnostic significance of hemorrhage under the skin is clearer when 
associated with profuse hemorrhages in other portions of the body, and 
when also there is a history of the occurrence of such hemorrhages 
in the family. The peculiar disease, hcemophilia, is attended by hemor- 
rhages without cause, and with the peculiarity that for successive genera- 
tions bleeders belonging to the male sex have been found, the disease 
being transmitted through the female members of the family. 

4. Hemorrhage in Central Nervous Disease and Neuritis. Mitchell 
has written of the neurotic origin of purpura. Subcutaneous hemor- 
rhages are seen in neuritis. 

Eruptions. Diseases of the skin are usually characterized by erup- 
tions. Now, such eruptions may be primary and local (from causes oper- 
ating directly on the skin) in the sense that they occur independently of 
any internal affection ; or secondary, the resultant of an internal morbid 
process. The morbid process in each does not differ, nor do we have 
morbid processes in the skin that differ, from the same in other epithelial 
structures. The anatomical and physiological peculiarity of the part 
causes the difference in the phenomena. Hence anaemias and hyper- 
emias, inflammations, acute or chronic, with or without exudation; 
hemorrhages, atrophies, and hypertrophies, new growths and parasitic 
affections are found. But instead of a painless inflammation with 
transudation of mucus, as in mucous membrane inflammation, we have 
a more or less painful inflammation, with itching (nerve supply) and with 
sebaceous and sudoriferous gland exudation. Otherwise the same symp- 
toms attend each, but ocular examination of the bronchial mucous 
membrane is not possible. 

Mode of Recognition. We recognize the process in the skin by inspec- 
tion, and differentiate the processes by inspection and palpation. 

While reference must be made to special works on skin diseases for 
a description of the primary or local skin affections, the secondary affec- 



80 



GENERAL DIAGNOSIS. 



tious will be briefly noted. It must Dot be forgotten that the local 
affections — eczemas, parasitic disease, etc. — are modified by the general 
condition or state of health of the patient. 

Clinical Significance. This depends, first, upon the special character 
of the eruption, the nature of the lesion ; second, its distribution — 
(a) in the layers of the skin, (6) over the surface of the body ; third, its 
association with other morbid phenomena or various circumstances. 

I. The nature of the lesion. Observation concerning the nature of 
the lesion includes (1) its anatomical character, (2) the order of appear- 
ance, (3) its uniformity, and (4) the mode of invasion. 

A knowledge of the anatomical lesions is essential in order to be able 
to define exactly the morbid process and apply the relationship of the 
lesion to the primary cause. For a long period of time the lesions have 
been divided into primary or secondary. The lesions known as scab, 
scales, raw surfaces, scratch-marks, and ulcers, are always secondary. 
Scars and maculae appear latest. The other lesions herein described are 
primary. The writer follows Dr. Pye-Smith in the description of them, 
as well as in most of the matter appertaining to cutaneous affections. 

1. Hyperemia, or congestion. 

a. Mere overfulness of the vessels from paralysis of the vasomotor 
nerves, with redness and heat, but without the exudation and tissue 
changes which accompany inflammation. This hypersemic blush, read- 
ily produced in the physiological laboratory, is rarely seen as an uncom- 
plicated morbid condition (e. g., Trousseau's tache cerebrale). 

b. Active, arterial, or inflammatory hypercemia, varying in color from 
brilliant scarlet to rose-pink, and combined with heat, tingling, or other 
sensations. 

c. Passive, venom, or congestive hyperemia, dependent upon retarded 
circulation and distended venules. The color is purple, bluish, or livid, 
the surface is cold, and there are no painful sensations. 

2. Pimple, or papule. A small, solid elevation of the skin. 
a. The acute inflammatory papule. 

6. The chronic large inflammatory papule, discrete or confluent. 

c. A solid non-inflammatory papule. 

d. Solid elevations of the skin, which may be called false papules. 

3. Vesicle. A visible cavity in the skin filled with transparent liquid. 

4. Pustule. A cutaneous abscess. 

5. Bulla, or bleb. A very large vesicle. 

6. Scab, or crust. A dried-up concretion of the contents of a vesicle, 
pustule, or bleb. 

7. Scale (squama). A dry flake of epidermic cells. 

8. Wheal (pomphos). A flat, solid elevation of the skin, much larger 
than a papule, and of ephemeral duration. 

9. Scratch-mark. An injury to the skin, of linear form and curved 
outline. 

10. Raw. A surface which has lost its horny layer of epidermis. 

11. Chap (rima). A crack or fissure which goes through the epi- 
dermis. 

12. Sore (ulcus). The result of destruction by inflammation, which 
has reached below the Malpighiau layer and has destroyed the papillae. 



THE DATA OBTAINED BY OBSERVATION. 



81 



13. Scar (cicatrix). The result of the healing process after an injury 
or disease deep enough to destroy the papilla? of the part. 

14. Nodule. A solid elevation of the skin larger than a papule, and 
seated in its deep layer. 

15. Stain {macula). A patch of increased pigmentation of the skin. 

16. Hemorrhage (ecchymosis). When a bloodvessel of the cutis vera 
gives way, a dark red or purple mark is produced, which (like the 
macula) does not disappear on pressure. 

The recognition of the exact anatomical lesion is not of sufficient 
purpose for diagnosis, unless at the same time the mode of invasion is 
observed. Often commencing at a focus, the rash spreads, or numerous 
foci appear and coalesce. The lesion is best studied in the more recently 
spreading part. Not only is the mode of local invasion to be noted, 
but also the uniformity of the anatomical lesion. Often, instead of a 
simple lesion, various kinds are present at the same time, or they develop 
in successive order, as iu smallpox we have first the papule, then the 
vesicle, and finally the pustule. 

II. Distribution. The location of the lesion in the various layers of 
the skin, and the distribution over the surface of the body, must be 
observed. The horny layers of the epidermis manifest pathological 
changes due to hypertrophy, atrophy, dryness or desquamation of the 
cuticle. Dead scales are the resultant, together with the hypertrophies 
and atrophies of the outline to follow (p. 92). The eruption in a large 
number of cases is limited to the living Malpighian layer of the epi- 
dermis and the papillary layer of the cutis. The hyperemias (erythe- 
mata), and inflammations of all kinds, are confined to these layers. They 
never leave scars in this situation. The deep layer of the cutis is so inti- 
mately connected with the subcutaneous tissue that morbid changes in 
it involve the latter, and even extend deeper. The affections are more 
severe, but less numerous thau affections of the superficial layers, and 
are always followed by cicatrices. The changes in the sweat glands, 
sebaceous glands, hair and nails, in so far as they refer to internal 
medicine, have been treated of in another section. 

The occurrence of the eruption in different areas over the surface of 
the body is of great diagnostic importance in the various erythemata 
due to the exanthems, or to morbid conditions of the gastro-intestinal 
tract. The distribution will be noted in more detail when their erup- 
tions are considered. The student should also bear in mind the rela- 
tionship of eruptions or cutaneous changes of nutrition (trophic disorders) 
to the affected nerve supplies. 

III. Associate morbid phenomena. The student of internal medicine 
should particularly observe the associated morbid phenomena, or con- 
comitant circumstances, in order to determine the nature of the skin 
affection which is the expression of an internal disorder. The associated 
morbid phenomena of diagnostic significance are fever, jaundice, 
albuminuria, past or present syphilitic disease, tuberculosis, rheuma- 
tism, or the phenomena of the rheumatic habit. The presence of 
either one of these processes points to particular affections. Thus a 
large number of these eruptions are attended with fever ; another group 
are of frequent occurrence in the course of rheumatism ; another class 

6 



82 



GENERAL DIAGNOSIS. 



belongs to syphilis, while a fourth class is associated with anaemia, 
jaundice, or albuminuria. This subdivision is not on the basis of 
the nature of the eruption, but of its association with other phenomena. 
It will be learned later that all the groups belong to the hemorrhages or 
erythemata. The true relationship of the two classes of phenomena 
can be ascertained fully only by inquiry into the history and course of 
the eruption and of the concomitant phenomena. Thus, if the erup- 
tion is thought to be due to the exanthemata the period of incubation, 
mode of infection, symptoms of the invasion, and the progress of the 
attack must be inquired into. 

General Symptoms. In order to determine accurately the cause of 
an eruption and appreciate its diagnostic significance, the general health 
must be inquired into, the condition of the stomach and bowels, and the 
character of the urine ascertained. It must be remembered that local 
skin disorders are influenced for good or ill by the general health. 
Functional disorders of the stomach and bowels are a frequent source 
of many of the erythemas, while in diabetes, pruritus and forms of 
dermatitis are of common occurrence. In Bright's disease also the 
latter are observed. The common cause for the eruption is the same in 
both, in all probability — that is, a perverted secretion of the skin, or, if 
oedema is present, impaired nutrition of the surface. 

The subjective symptoms are of further importance in the effort to 
ascertain the true nature of an eruption. Pain, itching, burning, 
smarting, and tenderness are significant of the inflammations. But, 
in addition, pains different from those which attend inflammation are 
present and characteristic. They are of a neuralgic nature, and while 
intermitting they are not limited to the area of the skin affection. They 
are distributed in the line of the nerve trunks of the adjacent regions. 
They often precede the development of the eruption. Pain of this 
character is seen in herpes zoster. Itching is an important symptom in 
disease of the skin. It is not present in the eruption due to the exan- 
themata generally, except in smallpox and rubella. Its absence is a 
striking peculiarity of the eruptions of syphilis ; but in erythema, espe- 
cially if associated with oedema, it is a most annoying symptom. Its 
presence in other skin diseases, as eczema, psoriasis, and the parasitic 
affections, is so much more common and of such extreme degree of 
annoyance that we may be safe, in the determination of the nature of an 
obscure eruption, in excluding the class which is particularly associated 
with internal diseases, by the presence of this symptom. 

Itching may be present without anatomical evidence of skin disease. 
It is seen in the troublesome pruritus that occurs in the aged, particu- 
larly about the intestinal and genito- urinary orifices, symptomatic of 
affections of the organs related thereto. It is a symptom which should 
lead to an examination of the urine, as diabetes is sometimes found to 
be the fundamental source of the complaint. It has been previously 
noted that in jaundice, itching to a high degree occurs. It is also due to 
the internal administration of drugs, as opium and morphine, and some- 
times quinine. 

In addition to the associate pathological phenomena which should be 
ascertained in the study of skin eruptions, in order to determine their 



THE DATA OBTAINED BY OBSERVATION. 



83 



relationship to internal affections, other circumstances should be inquired 
into, such as the occupation, the character of the clothing, degree of 
cleanliness of the patient, the effects of climate, including seasons, 
temperature, and state of the air. 

In order more thoroughly and yet in a concise manner to appreciate 
the various skin eruptions and their pathological relationship, the fol- 
lowing outline is included from the concise work of the author previously 
mentioned, to whom the writer is indebted for much of the data of this 
section. A study of the table likewise shows at once the relationship 
of the eruption to the internal disorders which concern us more particu- 
larly in this work : 

Diseases of the Skin regarded as Physiological Processes. 
[Pathological Arrangement.) 

Acute Inflammations. — Diffuse, e. g., scarlatina, morbilli, syphilis, roseola 
(eruptive fevers ; erythema). 

With venous congestion — Erythema nodosum (rheumatism). 

With oedema— Urticaria, erythema nodosum (gastro-intestinal disorder and 
rheumatism). 

With necrosis — Furunculus, anthrax (diabetes). 

Localized in papules — Enterica (erythemata), syphilis, eczema, prurigo. 
Localized in vesicles — Eczema, zona, variola, scabies, herpes, varicella (erup- 
tive fevers, infectious diseases). 

Localized in pustules — Impetigo, variola, scabies, syphilis, sycosis, acne. 
Localized in blebs — Pemphigus, scabies, rupia. 
Desquamating during involution — Scarlatina, etc. 

Chronic Inflammations. — With venous congestion — Acne rosacea, pernio. 

With over-production of epidermis— Psoriasis, pityriasis rubra. 

With oedema — Elephantiasis. 

With fatty degeneration — Xanthelasma. 

With hypertrophy — Elephantiasis. 

With cicatrization — Cheloid. 

With ulceration — Lupus, syphilis, lepra. 

New growths — Xanthelasma, lupus, lepra, syphilis, cancer. 

Atrophy — The senile skin, linese gravidarum. 

Hypertrophy — Ichthyosis, cornu cutaneum, clavis, verruca. 

Hemorrhage — Traumatic (e. g., flea-bites), typhus, scurvy. 

Pigmentation — Syphilitic maculae, melasma, chloasma, icterus, ephelis. 

Congenital malformations — Ichthyosis, cutaneous nsevus. 

Neurosis — Pruritus (diabetes, jaundice). 

Anomalies of Secretion. — Increased, diminished, or perverted — Seborrhoea, 
xeroderma, hyperidrosis, anidrosis, chromidrosis, etc. Obstructed — Comedo, 
milium, acne; sudamina. 

A glance at the above outline will show that the eruptions which 
particularly concern us belong to the class of diseases to which the term 
erythema is applied. 

Erythema. 1. Classification. Erythemata may be divided, in ac- 
cordance with the classification of Kaposi, into acute, contagious, exuda- 
tive dermatoses, represented by measles, scarlatina, rubella, and smallpox ; 
and the acute, non-contagious, inflammatory dermatoses, w T hich may be 
further subdivided into : First, typical forms, idiopathic and toxic, in- 
cluding urticaria, or nettle-rash ; second, varieties of herpes ; third, 
erythema due to boils, colds, or erysipelas. The first group of the now- 
contagious form includes the class which should always be considered in 



84 



GENERAL DIAGNOSIS. 



connection with the diagnosis of fevers. The skin inflammations 
closely simulate the eruptive fevers as to the eruption, the fever and 
even the affections of the mucous membranes. Besnier has named 
them the pseudo-exanthems, and divides them into the rubeoloids and 
scarlatinoids. Both simulate eruptive fevers throughout their course, 
and hence both are acute and febrile. The scarlatiniform erythemas 
are febrile at the beginning, subacute in course, but of longer duration 
than fevers they simulate. They are the most common forms, and arise 
from infectious diseases, such as puerperal fever, septicaemia and gonor- 
rhoea, or from toxaemia due to drugs or articles of food. 

2. Character of eruption. The erythemata are characterized by 
(a) rose rash with injection of the surface, either (6) with general 
oedema, or with circumscribed local oedema, forming wheals, or with 
papules. In rare forms bullae are also formed, (e) The rash is fol- 
lowed by a branny desquamation, (d) The exudation that attends the 
lesion is always watery, in contradistinction to the sero-purulent or 
purulent exudation ,of eczema and scabies. Sometimes slight hemor- 
rhages attend the lesion, as in cases of purpura or of urticaria, (e) The 
course of the erythema is of diagnostic significance. It begins quickly 
and is usually attended with febrile symptoms, sometimes mild, again 
very intense. (/) The duration is short ; at least it is not indefinite. 
The erythemas that are recurrent must not be considered to be one 
process of long duration. (g) The locality of the erythema is not of 
precise diagnostic significance. The eruption is usually symmetrical, 
and the favorable localities may be defined as the extensor surfaces of 
the forearms and leg, the face, cheeks, and neck ; and, thirdly, on the 
chest and abdomen. True erythema does not attack the scalp, the 
flexures of the joints, the palms (except erythema multiforme) and the 
soles, (h) The local symptoms that attend erythemata are mild. Local 
tenderness is more marked than in eczema. Smarting and tingling are 
complained of, but severe pain and excessive itching are rare. Only 
when wheals are present do we find pruritus. The rash of erythema 
does not spread. Patches occasionally unite, but an affected area never 
enlarges its borders. 

3. The cetiology of erythema is involved in obscurity. Although the 
frequent associate phenomena are not of ^etiological, they are certainly 
of diagnostic significance. We may have them occur under the fol- 
lowing circumstances : 1. In one class the eruption is symptomatic, de- 
pending upon dyspepsia or upon rheumatic fever. 2. In the eruptive 
fevers, especially scarlatina and measles, in enteric fever and cholera, and 
in syphilis, there is an early erythema preceding the later true eruption. 
3. The most striking instance of the relationship to internal disorder is 
seen in the rash that arises after the administration of medicine, as copaiba, 
or after the taking of certain foods. 4. The erythemata occur most com- 
monly in children and young people. They are very frequent in men. 
The age at which they occur coincides with that of rheumatism. 

4. Varieties. The following are the varieties of erythemata : First, 
erythema multiforme in simple form, with papules or with exudation; 
it may disappear in a few hours, or persist for a day or two and form 
rings {erythema fugax and erythema annulatum). With the fading of 



THE DATA OBTAINED BY OBSERVATION. 



85 



the redness faint desquamation follows, and there may be a few pigment 
marks. The annular form is observed in rheumatic fever. In addition 
to rheumatism as the cause of erythema multiforme, it may be found 
associated with the following affections : Typhoid fever, puerperal 
fever, gonorrhoea, cholera, infectious endocarditis and osteomyelitis, 
syphilis, leprosy, vaccination, and surgical septicaemia. 

Erythema Iceve often appears upon the tense skin of dropsical parts. 
It may be the result of acupuncture. 

Vesicular and bullous erythema. To this class belong the affections 
known as herpes and erythema bullosum. Herpes zoster is observed in the 
cutaneous distribution of one or more nerves. It consists of vesicles of 
flattened form ranged in clusters of twenty or thirty lying on a reddened, 
slightly swollen bed of skin. The number of clusters varies from one to 
ten. The vesicles develop in quick succession, beginning usually at first 
nearest the roots of the nerve whose branches they follow. A short pap- 
ular stage precedes the vesicles, and some of the vesicles abort. The erup- 
tion tends to dry up in five or six days. The crusts form in yellowish or 
brownish clusters, which fall off in the third week, leaving purple stains. 

When the disease attacks the face the fifth nerve is followed in its 
course. The several twigs of the trifacial are traced out from their 
points of emergence from the bony canals. Great swelling of the eye- 
lids sometimes takes place on account of the loose tissue, so that the 
lesion may be mistaken for erysipelas. Ulceration of the cornea and 
iris sometimes occurs, and when lower divisions of the trifacial are 
affected, vesicles may appear in the mucous membrane of the mouth and 
palate. The cervical nerves and those of the upper extremity are also 
affected in their distribution. The eruption on the arm rarely goes 
below the elbow. When the second and third intercostal nerves are 
affected, the intercosto-humeral branch produces an eruption down the 
inner side of the arm. The eruption occurs frequently on the trunk. 
Following the course of the dorsal nerves it slants downward as it 
approaches the pubes. 

In the distribution of the disease in the lower limbs the eruption 
rarely extends below the knee or buttocks. It follows the course of 
the external cutaneous or anterior crural nerves, or that of the small 
sciatic. Some of the branches of the sacral nerves are also affected. 
The disease is unilateral, and its precise limitation to one-half of the 
body is of the greatest diagnostic significance. 

While fever or general symptoms do not usually attend its course in 
any extensive degree, insomnia and depression are likely to occur, probably 
on account of the severe neuralgic pain. Pain is the most important sub- 
jective symptom. It is localized in the nerves in the distribution of which 
the eruption takes place. It is not so likely to be present in the young. 
The pain may precede the eruption by several days, and persist long 
after the eruption subsides. This is particularly the case in old people. 

Herpes labialis, or facialis, consists of vesicles arranged in groups or 
clusters upon a red patch of skin. They appear very suddenly upon the 
upper lip or the alae of the nose ; sometimes on the cheek or chin, and 
they may appear inside the mouth. They undergo some changes, as in 
herpes zoster, but are not attended by the neuralgic pain. They are 



86 



GENERAL DIAGNOSIS. 



always symptomatic of an internal disorder, an acute catarrh (cold), or 
follow a rigor, as in intermittent fever or pneumonia. Herpes iris and 
herpes praeputialis have no diagnostic significance of internal disease. 

M-ythema nodosum. With the erythema there is great oedema. 
The spots are somewhat painful and tender, but do not itch. The red- 
ness of the erythema is modified by the hue of venous congestion. 
Small hemorrhages may be seen. The patches develop on the legs, 
their long diameter being parallel to the tibia. They rise slowly into 
hard masses. They may be seen on the ankles or the calf, and some- 
times on the ulna. They occur frequently in those who have suffered 
from rheumatic fever. 

Urticaria is a form of erythema in which wheals, sometimes sur- 
rounded by an erythematous blush, are seen. It is an acute inflamma- 
tory oedema of the cutis The serous exudation fills the lymph spaces 
and expels blood from the venules. It takes place suddenly, and may 
be excited by chemical irritation or a mechanical irritant, as the finger 
drawn across the skin. Small patches, or large white areas, are seen, 
due to the coalescence of smaller ones (giant urticaria). All parts of the 
body may be affected, except the scalp, face, and soles of the feet. The 
eruption is not symmetrical. Its course may be acute, or it may be 
chronic and transitory, characterized by successive attacks. It is the 
form of erythema in which intense itching is the most pronounced 
symptom. There are no other subjective symptoms. The itching 
causes restlessness and loss of sleep. Urticaria is symptomatic of 
gastric or intestinal disturbance, or the ingestion of drugs or poisons. 
Another form follows the tapping of a hydatid cyst. It occurs some- 
times in women at each menstrual period, and may be traced to ovarian 
disorder. It may occur after severe shock to the nervous system, with 
high fever. It is not an infrequent complication of rheumatic fever. 
It occurs in men and women equally, but is most frequent in children 
and adolescents. 

Medicinal Rashes. To the erythemata belong most of the so- 
called medicinal rashes. 

The following drugs are known to cause erythema : bromide and 
iodide of potassium, copaiba, cubebs, the essential oils, capsicum, 
santonin, chloral, opium, morphine, antipyrin, salicylic acid and its 
compounds, iodoform, belladonna and atropine, tar, carbolic acid, arsenic, 
cannabis indica, digitalis, mercury, silver, and copper. 

Belladonna produces in susceptible persons, or when administered in 
poisonous doses, a diffuse bright-red erythema, closely resembling that of 
scarlet fever, but without the darker red points which interrupt the latter. 
Atropine also produce in some persons, especially on the shoulders, arms, 
chest, and face, an eruption of disseminated, small, hard vesico-papules, 
showing no tendency to pustulation. They are seated on an inflamma- 
tory base, but are more superficial than acne. 

The bromides produce a characteristic pustular eruption which is most 
intense upon the shoulders, face, chest, aud arms. Large closes or long- 
continued administration is generally required to bring it out. It is 
conspicuous upon the face of some epileptics. 

The iodides produce an eruption which is not frequently pustular, 



THE DATA OBTAINED BY OBSERVATION. 



87 



but an erythematous rash is not uncommon. It appears chiefly about 
the forearms, face, and neck. Vesicles, bullae, and purpuric spots are 
also occasionally seen. 

The eruption produced by quinine is generally erythematous, and is 
attended with itching and burning ; the face and neck are attacked first. 

Opium aud its alkaloid also produce in susceptible persons an erythe- 
matous scarlatinoid eruption which is accompanied with intense itching. 
Itching, especially about the nose, is much more common without an 
eruption. 

Copaiba produces a vesico-papular or papular eruption which resem- 
bles urticaria and erythema multiforme. It is itchy. It is more apt to 
be seen on the extremities. It may be purpuric. 

The eruption of cubebs is a diffused erythema, with millet-sized 
papules, coalescent here and there. Unlike the eruption of copaiba, it 
is more copious over the face and trunk than over the extremities. 

Antipyrin causes a measles-like or urticaria-like eruption. 

Erythemata of Infectious Diseases. The inflammations of the 
skin which are symptomatic of a specific infection are also of an erythe- 
matous variety. The term exanthemata has been applied to the latter, 
but the eruption of typhus aud typhoid (enterica) belong to the same 
class. The characteristics aud distinctions of the various forms will be 
described in sections devoted to the respective diseases. The student 
should remember the association with the general phenomena, particu- 
larly fever, the ouset and course of which should be carefully observed. 
But to add to the confusion an erythema called roseola often precedes 
the fever. 

Roseola. The rashes which precede the eruptive fevers are very 
liable to lead one astray as to the recognition of the true disease. Their 
association with this class of fevers has been indicated before. The form 
of erythema known as roseola, or rose rash, is especially seen. It is of a 
deep rose color, not arranged in crescentic patches, as in measles, nor 
scarlet and capable of being resolved into innumerable red points, as in 
scarlatina. It is not so diffuse as the latter. It precedes smallpox, 
scarlatina, measles, cholera, typhoid fever, syphilis, diphtheria, and 
malaria. In smallpox, in cases of cholera, and after parturition and 
surgical operations, the rash is copious, but is characterized by its being 
seated over the lower half of the abdomen and the anterior aud inner 
aspect of the thighs. It may appear elsewhere, but is generally con- 
fined to that portion of the body. Erythema roseola may be mis- 
taken for rubella, measles, or scarlatina. The following are points of 
distinction. First, it is not contagious and is not epidemic ; second, there 
are no prodromal symptoms ; third, the rash does not come out after a 
definite period of fever ; fourth, it is not confined to any special locality 
of the body ; fifth, the fever is of short duration and moderate degree, 
rarely above 101° ; sixth, there is no catarrhal discharge from the eyes 
or nose or in the pharynx ; the fauces and palate are reddened, without 
swelling ; seventh, it is not seen in the mouth, like the eruptions of 
measles or scarlatina ; eighth, the fever which precedes the eruption, if 
present, is of only a few hours' duration (in scarlatina it is twenty-four 



88 



GENERAL DIAGNOSIS. 



hours, in measles seventy-two hours) ; ninth, the rash is not crescentic 
as in measles, or punctiform as in scarlatina, though it is to be admitted 
that severe cases of the affection cannot be easily diagnosticated, the 
development of the sequelae alone concluding the diagnosis. 

Sufficient reference has been made to the erythemata that attend 
rheumatism. A few other internal (infectious) disorders are associated 
with the development of an eruption. In cholera, during the period of 
reaction, a rose rash which may resemble erythema, urticaria or scar- 
latina appears coincidently with a rise of temperature. It is most fre- 
quently seen on the forearms and back of the hands, but may cover the 
back and limbs. It may be slightly hemorrhagic and last two or three 
days. A slight desquamation usually follows. In influenza a roseolous 
eruption, covering the trunk and limbs and becoming papular, is seen 
rarely. 

In addition, in the course of Bright' s disease erythematous eruptions 
are sometimes seen. Quite distinct from erythema lseve, previously 
mentioned, two forms are observed, the roseola on the feet, legs and 
hands, rarely on the chest and abdomen, and the papular form on the 
thighs, arms and shoulders ; itching and other subjective symptoms do 
not attend the eruption. A form with desquamation may begin on the 
limbs. These erythemata are common in the later stages of Bright's 
disease, but are not of ill omen. In acute Bright' s disease a transient 
roseola is observed very rarely ; so also is purpura. If there is much 
anasarca in tubal nephritis, erythema is more common. The eruptions 
generally appear independently of urasmic symptoms, and disappear 
during their continuance. They are allied in all probability with the 
inflammation which attacks the lungs and serous membranes in Bright' s 
disease. 

Sudamina. Here may be placed another eruption or condition of 
skin, common in the course of internal diseases. Sudamina, ov miliaria, 
are small, clear vesicles seen in large numbers, generally on the abdomen, 
but also on any other part which reflects the light strongly. They are 
seen after the subsidence of anidrosis, when profuse sweats occur. 
While actual perspiration is seen on the forehead, the trunk may appear 
free from moisture. When the hand is placed over it, as on the abdomen, 
the dryness is noted, but at the same time a roughened, nutmeg-grater- 
like sensation is present. On close inspection this is observed to be 
due to the eruption just mentioned. The vesicles are usually of good 
prognostic omen in the course of febrile diseases, particularly typhoid 
fever. They are due to the accumulation of perspiration under the 
epidermis. 

General Diagnosis of Skin Affections. 

[Condensed from Pye-Smith.) 

I. Factitious Eruptions. We must never forget the possibility of 
the affection before us being artificial. All kinds of dermatites, eczema, 
erysipelas, pemphigus, impetigo, may be simulated by the application 
of various irritants. Pigmentation also has been often imitated with 
success. Such artificial lesions will generally be found upon the arms, 



THE DATA OBTAINED BY OBSERVATION. 



89 



rarely on the face, and scarcely ever beyond reach of the patient's 
hands. Mustard, cantharides, and some other irritants can be dis- 
tinguished by help of the microscope. 

II. Traumatic Eruptions. In all cases of dermatitis we should 
seek for the irritant, and sometimes it is so directly the cause of the 
disease that the eczema or impetigo in question may be considered 
purely traumatic, and efficient treatment immediately follows accurate 
diagnosis : sublata causa tollitur effectus. 

Pediculi in the hair should be carefully looked for in all cases of 
impetigo in children, pediculi vestimentorum in prurigo of old people. 
The acarus of scabies, fleas, bugs, and gnats, should be looked for. In 
adults pediculi pubis may sometimes be found in the axillae as well as in 
their proper region, and when they have been destroyed by mercurial 
ointment the patient is at once relieved from pruritus. 

In many trades an irritant must be sought in the objects which the 
patient habitually handles. The coarser kinds of brown sugar are a 
frequent cause of eczema of the hands (grocer's itch). So with many of 
the "chemicals" used in a variety of modern handicrafts. Constant 
washing of the hands in washerwomen, in scrubbers, in potmen, and 
many others, produces eczema rimosum. The heat of the sun is the 
cause of eczema solare and ephelides ; the heat of the fire, of the pigment 
spots on the shins of elderly people. Sweat, again, is a very common 
irritant, producing the erythema which usually accompanies sudamina 
and also intertrigo of opposed surfaces. Scratching, as a cause of 
traumatic dermatitis, has been repeatedly referred to. 

III. Febrile Rashes. We must take care never to forget the possi- 
bility of a cutaneous eruption being part of an acute exanthem. The 
use of a clinical thermometer is a great help in this respect. Variola is 
frequently mistaken for syphilis and other affections. 

IV. Other cases are due to certain kinds of food or to drugs. 
They have been described above. 

V. Syphilodermata. When we have satisfied ourselves that the 
eruption before us is not factitious, nor directly traumatic, nor a symp- 
tomatic eruption, we may next consider whether or not it is due to 
syphilis. In this inquiry it is undesirable to ask questions, the answers 
to which are as apt to mislead as to guide aright. 

1. We should first consider the color of the affected skin, remem- 
bering, however, that the pigmentation w 7 hich gives the so-called coppery 
or raw-ham tint to a syphilitic eruption is the same which is sooner or 
later produced by all forms of dermatitis. Psoriasis, chronic eczema, 
lichen planus, and prurigo, may all produce shades which bear the 
closest resemblance to syphiloderma. 

2. The lesions of syphilis are multiform. It is rare in any 
but syphilitic affections to find mere hyperemia in one part, and 
associated pustules, papules, scales, or ulcers, in others ; and it is not 



90 



GENERAL DIAGNOSIS. 



often that a syphilitic eruption exhibits only a single elementary 
lesion. 

A pustular eruption in an adult should always suggest the question 
of syphilis when that of scabies has been answered in the negative. 

3. Syphilitic eruptions, for some unknown reason, do not itch — 
the exceptions to this rule are remarkably few ; they usually occur 
during the stage of scabbing of pustular rashes or during the healing of 
tertiary ulcers. An ordinary secondary syphilide may, however, as a 
rare exception, be so irritable that wheals and scratch-marks are produced. 
On the other hand, psoriasis is often free from irritation, while the 
degree of itching of eczema, and even of scabies and prurigo, varies 
greatly. 

4. The local distribution of syphilitic disease is a great aid in diag- 
nosis. Specific eruptions are certainly not, as a rule, symmetrical ; the 
early roseolous rash is only so because it is general, and therefore, upon 
a surface like the human body, more or less symmetrical. Moreover, 
as it chiefly affects the face, chest, and trunk generally, it is near the 
middle line. But we do not see symmetrical patches of syphilide in 
corresponding parts of both sides of the face, both sides of the trunk, or 
the right and left limbs. In all but the earliest syphilides the affected 
patches are very decidedly and constantly unsymmetrical, irregularly 
scattered over head, trunk and limbs, and chiefly remarkable for having 
no well-marked seats of predilection. 

The forehead, especially about the roots of the hair, is, however, very 
frequently the seat both of the early and middle erythematous, scaly, 
and pustular syphilides, and the palms of the hands and soles of the 
feet are frequently symmetrically affected with the later scaly erup- 
tion. 

Practically, when we find a disease of the skin occupying some 
unusual position we should at least consider the question of syphilitic 
origin. 

5. These signs alone or in combination serve to distinguish early 
specific roseola from erythema, eczema, scarlatina and measles, and the 
later eruptions from eczema, lichen, scabies, impetigo, and psoriasis. 

The eruptions of congenital syphilis which are most liable to be mis- 
taken are : The so-called pemphigus of infants, which is known by its 
affecting the palms and soles ; rupia, which, by the form of the crusts 
and the ulcerated surface beneath, may always be distinguished from 
impetigo ; an erythematous rash of the nates and genitals of infants, 
which is distinguished from eczema of the same parts, also common at 
that age, by its coppery color, its blotchy distribution, and more defined 
margin. 

The tertiary ulcers of syphilis are distinguished by their appearing on 
unusual places, by their punched-out edges, circular or so-called horse- 
shoe shape, and by their usually producing little pain or discomfort. 
Tertiary ulcers have no predilection for the outer side of the leg, but 
inasmuch as the part above the inner angle is, for auatomical causes, the 
chosen seat of varicose ulcers, most ulcers in the first position will be 
syphilitic and in the latter not. For the same reason most ulcers on 
the arms are found to be tertiary. 



THE DATA OBTAINED BY OBSERVATION. 



91 



VI. Tineee. The next group of skin diseases includes those which 
are due to vegetable parasites — tinea versicolor of the trunk, eczema 
marginatum of the perineum and thighs, tinea circinata of the neck and 
other parts, tinea sycosis of the chin, and tinea tonsurans of the scalp. 
In all doubtful cases the microscope should be employed. 

Tinea of the scalp is rare in adults, and tinea circinata still more so ; 
tinea marginata occurs only in adult males. 

VII. Primary Superficial Inflammations. To distinguish the 
superficial from the deeper kinds of dermatitis, we should notice whether 
the cutis alone is infiltrated and thickened, or whether it is bound down 
by adhesions to the subcutaneous tissues. The presence of scars, how- 
ever slight, is a proof that the process has gone deeper than the papillae, 
and has more or less extensively destroyed the papillary layer. Super- 
ficial inflammations, excluding those due to the acarus, to pediculi, and 
to other direct irritants, and excluding also those which are the result 
of vegetable parasites and of syphilis, fall with respect to their treatment 
into three large groups : 

The first group, represented by impetigo and most forms of eczema, 
consists of inflammations which are subacute, and accompanied with 
burning, itching and pain, sometimes with a slight degree of fever. 

The second group of superficial inflammations of the skin is typically 
represented by psoriasis, but includes lichen planus, the more chronic, 
dry, and obstinate forms of eczema, and true prurigo. These affections 
are chronic, with little irritation, exudation, pain, or active signs. 

The third group is that of erythemata. 

VIII. The Acne Group. Acne, both in its pathology and etiology 
differs from other forms of dermatitis. The age of the patient, and its 
distribution, are sufficient for diagnosis. It is at once a superficial and 
a deep dermatitis, and is often followed by scars. Its treatment con- 
sists entirely or almost entirely in local applications directed to the 
correction of the sebaceous affection. With acne may be classed sycosis 
and furunculus. 

IX. Deep Affections. When we have ascertained that the affection 
of the skin is deep, that is to say, that it goes below the papillary layer, 
the field of diagnosis is limited. 

Excluding erysipelas, which is distinguished by its acute character 
and febrile symptoms, excluding the pustular affections which affect the 
skin deeply and produce scars only at isolated points, such as acne, 
variola and zona, and excluding, thirdly, leprosy and other exotic 
diseases, we have to distinguish in the great majority of cases which 
come before us in this country — first, traumatic and varicose ulcers ; 
secondly, gummata and syphilitic ulcers; third, lupus; fourth, rodent 
ulcer, and carcinoma of the skin. 

With regard to the first of these, we must not assume, because a sore 
upon the skin is said to be the result of a blow or a kick, that it 
is purely traumatic, for syphilitic ulcers often arise in this way. Malig- 
nant ulcers are rare, and are usually obvious from the age of the patient, 



92 



GENERAL DIAGNOSIS. 



the pain they occasion, their tumid margins, and their blood-stained 
secretions. Moreover, they are, with few exceptions, confined to the 
neighborhood of the orifices of the body, especially the lower lip, the 
urethra, the vulva, and the anus. Rodent ulcer, however, is very diffi- 
cult to be sure of. Its locality, its slow and painless progress, and its 
belonging to the latter half of life, usually serve to distinguish it from 
lupus ; and its being single, excessively chronic, and unaccompanied by 
nodes or other syphilitic lesions, are the best characteristics for diagnosis 
from a tertiary ulcer. 

The Subcutaneous Connective Tissue. Swelling of the surface 
is an indication of change in this tissue. OEdema, myxcedema, subcu- 
taneous emphysema, dystrophies, scleroderma, brawny indurations, and 
local subcutaneous swellings are the principal ones to be considered. 

CEdema ; Dropsy. The lymph spaces of the subcutaneous connective 
tissue become overdistended with serum, causing an accumulation to 
which the general term dropsy is applied. If the accumulation is local 
and confined to small areas, it is known as oedema If it is general, 
and in addition the large lymph cavities, the pleura, the peritoneum, 
and the pericardium contain fluid, it is known as anasarca. Accu- 
mulation occurs because more fluid is poured out by the vessels than 
can be removed by the lymphatics and veins. This may depend either 
upon obstruction of the veins and lymphatics or excessive exudation from 
the bloodvessels or both. The former condition, however, is rare, and 
usually local, because, unless the obstruction to them is very great, the 
veins and lymphatics are able to carry away more fluid than is effused from 
the capillaries. (1) Local capillary change from inflammation or the 
effects of poisons. The change, therefore, as often seen, must be due to 
some process in the capillaries. Formerly it was thought that this general 
process was of an inflammatory nature, but at present it is believed to 
be due to the influence of poisons, probably absorbed from the intestinal 
canal, modifying and altering the nutrient small vessels. Thus the 
cedema and general dropsy of albuminuria, particularly in the early 
stage of that affection, is thought to be due to a common poison circu- 
lating in the blood, which also causes the nephritis. 

Brunton (to whose article I am indebted for these remarks) states 
that Mahomed found a pre-albuminuric stage of scarlet fever, in which 
he noticed a peculiar reaction of the urine, which gave a blue color with 
guaiac. A brisk purgative when this reaction was noticed would pre- 
vent the occurrence of albuminuria ; whereas, if the drug was withheld, 
albuminuria always followed. The purgative removed the poison which 
caused the nephritis and oedema.. It is well known that in urticaria there 
is marked local cedema. Brunton thinks that some poisons circulating 
in the blood cause paralysis of the secreting power of the sweat glands, 
on account of which there is not only effusion from the bloodvessels, 
but at the same time such changes in the secreting cells take place as to 
produce an acid, the local action of which, upon the capillaries, causes 
a further transudation of fluid. That acids circulating in the blood have 
the power of creating oedema, the experiments of Cash and Brunton fully 



THE DATA OBTAINED BY OBSERVATION. 



93 



demonstrate. While, therefore, in the oedema of Bright's disease in its 
earliest stage, and in urticaria, we have this explanation for the phe- 
nomena, other factors are causal in other forms of oedema. (2) (Edema 
will occur whenever there is obstruction to the flow of lymph. This 
obstruction may be in the lymphatics or the veins. In the former it 
may occur (a) from waut of muscular action ; (b) from want of in- 
spiratory action of the thorax ; (c) diminution of the diastolic suction 
of the heart ; (d) positive pressure on the veins. In the latter, obstruc- 
tion of the veins is caused by conditions similar to that in the lymph- 
atics, and arises from (a) want of muscular action ; (6) want of movement 
of the thorax ; and (c) feeble action of the heart ; and in addition 
it is likely to be caused by (c?) complete arrest of blood flow from 
pressure upon the vein from without, or plugging within. It can readily 
be seen, with a little knowledge of physiology, how the above factors 
favor the development of the second common form of oedema, namely, that 
due to disease of the heart and to venous obstruction. The baneful factors 
are those which retard the flow of blood. Hence, the oedema of passive 
congestion. (3) A third form of oedema, usually slight, occurs in cases 
of anaemia. Several factors combine to produce it; (a) the watery 
condition of the blood ; (b) the condition of the capillaries ; and (c) 
vasomotor paresis on account of imperfect nutrition of the vasomotor 
centres. Finally, (4) oedema may be of nervous origin. The oedema 
that occurs in diseases or injuries of nerves belongs to this class. Thus 
far no satisfactory explanation has been given, unless it arises because 
of alterations in the permeability of the vascular walls. 

Mode of Recognition. Whether the accumulation is in the lymph 
spaces, in local areas, or engorging the entire subcutaneous tissue, the 
oedema is not difficult of recognition. The part is swollen, the surface 
is pale, the temperature is usually low, and the affected area pits on press- 
ure. This is more pronounced if pressure with the finger is made over 
a part which is seated upon a firm background, as bone. (Edema of the 
ankle or over the tibia is more readily recognized than oedema in the calves. 

(Edema is to be distinguished from — (1) Inflammatory swellings, by 
the absence of the classical signs of inflammation, pain, heat, and red- 
ness. (2) Swelling due to myxoedema differs from oedema in the 
absence of pitting on pressure, the occurrence of induration, which 
resists the pressure of the finger, and in the occurrence of anaesthesia or 
analgesia. (3) Swelling due to connective tissue dystrophies are excluded 
because they are hard localized areas that do not pit on pressure, and 
that are not seated in dependent parts of the body. They are found on 
the arm, for instance, or on the leg, or about the flanks and in the 
axillae. (4) The subcutaneous swelling due to emphysema differs from the 
swelling of oedema, in the fact that it arises in the course of some disease 
of the air-passages and on palpation the crackling sensation of air under 
the finger is distinctly felt, while there is no pitting on pressure. In the 
cases that the writer has seen the parts were particularly tender, although 
pain is said to be absent usually in subcutaneous emphysema. 

Diagnostic Significance. The significance of oedema depends 
upon its location, its mode of development, and its association with 
disease of other organs or structures of the body. 



94 



GENERAL DIAGNOSIS. 



Situation. The oedema may be local or general. 

Local (Edema. Local, or at times unilateral, oedema occurs when 
there is pressure on a vein or occlusion of it by a thrombus. (Edema of 
the arm, on account of disease of the lymphatic glands in the axilla, 
and oedema of the leg, on account of thrombosis of the femoral vein, are 
examples of this form of local oedema. Of marked diagnostic signifi- 
cance is the local oedema that is seen over inflammatory areas. It is 
an indication of suppuration. It is due to obstruction of the lymph 
circulation. It is seen over the mastoid when its cells are the seat of 
inflammation ; over the parotid gland under the same circumstances ; 
at the side of the thorax in empyema ; over the prsecordia in purulent 
pericarditis ; over the surface of the liver in some cases of hepatic 
abscess ; in the abdominal parietes in purulent peritonitis, but more 
marked at the primary focus of inflammation, as the gall-bladder region 
or the region of the appendix. 

GEdema from the above causes is of local orgin. (Edema from general 
causes usually develops gradually and begins in special localities. We 
are accustomed to see it in the course of various affections at first in the 
feet or the face. 

The Feet. (Edema of the feet or ankles is usually due to disturb- 
ance of the circulation, and is a form that arises in heart disease, or in 
the course of any exhausting and debilitating disease in which the 
nutrition of the heart has suffered seriously. The organic change (dila- 
tation) which takes place in the heart-muscle in the course of obstructive 
valvular disease and in lung disease is attended by oedema, beginning at 
first in this situation. Later a general dropsy may ensue. But oedema 
of the feet may occur from another cause, i. e., anosmia. In all forms 
of anaemia puffiness of the ankles is seen. An explanation of the cause 
has been given. Similar localized oedema occurs in individuals of relaxed 
fibre, in the evening after a day of considerable physical exertion. 

(Edema of the Face. (Edema may begin or remain localized in the 
face, and is very striking. (See Face and Eyelids ) It may be limited 
to the eyelids, as a simple puffiness, or may spread over the entire face, 
causing complete obscuration of the normal outlines. The signs of oedema 
are not different from those of other situations. It is the oedema of renal 
disease, and as a special characteristic differs from oedema of the feet in 
that it disappears toward night and is more marked in the morning on 
rising. Of all forms of local oedema it is the most grave, and should 
at once command attention to the condition of the urine, particularly 
if the patient has just had an attack of scarlatina, or if it occur in a 
female who is pregnant. 

The Arms and Thorax. Another form of local oedema, bilateral 
in situation, occurs when there is internal pressure within the thorax 
on account of aneurism, or disease of the mediastinal glands. The 
oedema is then limited to the arms, or to the arms, head, neck, 
and thorax. Such oedema is usually associated with cyanosis of the 
hands and arms. There is also marked distention of the veins of the 
upper part of the body. The oedema has been found, in a few instances, 
to be more marked on one side than the other. This has occurred in 
cases of aneurism in which the sac of the aorta communicated with the 



THE DATA OBTAINED BY OBSERVATION. 



95 



vena cava. Either the collateral circulation on one side had been 
established, or pressure was greater on the left innominate vein. The 
oedema is sometimes limited to the head and arms. If the obstruction 
of the superior cava was situated below the entrance of the azygos vein 
the chest shared in the venous congestion and resulting oedema. If, on 
the other hand, the obstruction was above the azygos vein there was 
no oedema of the chest wall, (Edema of this character is usually easily 
recognized, because of the symptoms above indicated, with other 
pressure symptoms due to disease of the mediastinum and with the 
results of physical examination, which reveals the presence of a tumor 
in the thorax. The above-described oedema usually develops slowly, 
hand-in-hand with the other symptoms. At times, however, it occurs 
suddenly. Sudden cedema in this situation is always due to an aneur- 
ism, which has ruptured into the vena cava (see above). The sudden 
onset is attended by physical signs of aneurism, or, if they are not 
present, by a murmur characteristic of the communication between an 
artery and a vein. It must be confessed that often the physical signs 
are not precise and the murmur is absent. The suddenness of the 
peculiar localized oedema is the chief point of diagnosis in favor of this 
rare form of aneurism. 

The (Edema of Trichinosis. (See Face.) In addition to the face 
(which see), oedema of the skin over the affected muscles is common. 
This oedema occurs early in the disease, disappears after a few days, to 
return again later. It is localized in the muscles, and is associated with 
the growth of trichina? in them. It is distinguished from cardiac and 
renal dropsy by the above means and by the fact that the scrotum and 
labia majora are never oedematous. 

General (Edema. (Edema of the face and feet may become gen- 
eral. In cases in which the face is first oedematous, its extension may 
be very rapid, so that twenty-four to forty-eight hours after the swelling is 
noticed the whole body is in a state of anasarca. The extension of oedema 
which primarily was seated in the feet and legs (cardiac dropsy), through- 
out the rest of the body is more gradual, and develops along with signs 
and symptoms indicating weakness of the heart. As it advances, in con- 
trast with the oedema of Bright' s disease, the hue of t'he patient changes. 
Cyanosis gradually appears. This may be seen first in the extremities, 
which are also oedematous. Finally the face and lips take on this pecu- 
liar hue. On the other hand, in the general anasarca that follows the 
local oedema of the face, of Bright's disease, pallor occurs, and as the 
oedema increases it becomes more and more of a waxy hue. With the 
waxy hue of the face, the extremities become glistening or shining in 
appearance. 

Angio-neurotic CEdema. This curious affection is not of frequent 
occurrence. It may be present in the individuals of several generations 
of a family. The attack comes on suddenly. The swelling is cir- 
cumscribed. It may appear on the face, on the brow, the lips or cheek. 
The eyelid is a common situation. It may also occur on the backs of 
the hands, the legs, or in the throat. It remains but a short time, and 
disappears as quickly as it came on. The outbreaks have exhibited 
distinct periodicity. Local symptoms of itching, heat, or redness, or 



96 



GENEKAL DIAGNOSIS. 



general urticaria may precede the swelling. The sudden swelling causes 
great deformity. If the upper lip is affected the mouth canuot be 
opened ; if the hands, the fingers cannot be bent. In the hereditary 
cases the attack recurs every three or four weeks. The danger to life 
is from oedema of the larynx, which caused death in two of Osier's 
cases. The general symptoms that attend the attack are gastrointes- 
tinal. Nausea and vomiting, followed by severe colic, occur. 

It must not be confounded with simple urticaria, or the giant form of 
that affection, with which it may, however, have close affinities. It has no 
relation to arthritic affections. It is regarded by Quincke as a vasomotor 
neurosis, on accouut of which the permeability of the vessels is impaired. 

Recapitulation. From what has been said above the student will 
observe that oedema may be local or general ; that local oedema may 
be unilateral or bilateral ; that oedema may further be subdivided, in 
accordance with the cause, into inflammatory dropsy, oedema or dropsy 
of passive congestion, hydrsemic dropsy, and vasomotor dropsy. The 
forms of passive dropsies just indicated may be subdivided into cardiac 
dropsy, hepatic dropsy, and renal dropsy, dependent on the anatomical 
cause for the dropsy. 

While the account of oedema just given refers more particularly to 
the subcutaneous accumulation of serum, the same pathology and aeti- 
ology apply to accumulations in the large lymph cavities, and hence 
in addition to general oedema we may have ascites, hydro-pericardium, 
hydrothorax, hydrocele, and effusion in the joints. The method of recog- 
nition of dropsy of the larger cavities will be deferred until diseases asso- 
ciated with these particular regions are discussed. It must be remem- 
bered that oedema or accumulations of serum in cavities may be of local 
or general origin. 

It must not be forgotten that two or more causes may combine to 
form a dropsy, or that a dropsy of one cause may for a time be dependent 
upon a second and even a more pronounced factor later on in the devel- 
opment of the disease. Thus (a) the dropsy of an hydremia may be 
aggravated by that of (b) a weak heart which arises from anaemia, to 
which may be added later the dropsy of vasomotor paresis. The dropsy 
of Bright's disease is due to (a) capillary changes produced by a poison 
circulating in the blood, and (b) later, to the condition of the heart, which 
frequently undergoes dilatation. 

Myxcedema. Swelling of the surface of the body, local or general, 
is also seen in myxoedema, a condition which simulates dropsy, the dis- 
tinction from which has been referred to above. In myxoedema the 
swelling is general. The face is involved. The arms are more markedly 
swollen, however, than the fingers ; the legs more than the feet. The 
swelling is due to the infiltration of mucin into the connective tissue, 
and arises from some affection of the thyroid gland. The gland is absent, 
functionally or actually. The hard, indurated, non-pitting swelling is 
associated with striking change in the appearance of the face, particu- 
larly the nose and forehead. The nose becomes thickened, the forehead 
more prominent and overhanging. The outline of the face is rounded, 
so that the term " full-moon " is applied to it. The skin is thickened, 



THE DATA OBTAINED BY OBSERVATION. 



97 



dry, and rough, somewhat translucent in appearance, of a doughy con- 
sistence, with a moderate degree of elasticity. The perspiration is 
diminished. The hands change in shape, they become square or spade- 
shaped, and the fingers clubbed. The appendages of the skin change. 
The nails become brittle and distorted, the hair dry, harsh, and brittle, 
and it may fall out. With these remarkable changes in the exterior, 
marked nervous and mental symptoms arise. Speech is thick and hesi- 
tating, the memory feeble. The intellect is dull and irresponsive, the 
temper irritable. Sensibility is impaired, particularly in the loss of 
sensation to pain. Patients have been burned without their knowledge. 
This occurred to considerable depth of tissue in one of the writer's cases. 
Abnormal sensations of heat and chilliness are complained of, as well as 
other paresthesias. The patient is anemic, the temperature is subnor- 
mal, the heart's action weak, the respiration sluggish. Breath lessness 
on slight exertion is pronouuced, and exertion itself is very difficult, 
while there is greater sense of fatigue than the exertion and the condi- 
tion of the organs would warrant. The muscularity is enfeebled. There 
is impairment of appetite, indigestion, and flatulency. The urine may 
become albuminous, but for a long time is not characteristic save in 
amount and specific gravity. The former is increased, the latter lowered. 

As the case advances mental and physical failure becomes more pro- 
nounced, the patient is subject to hallucinations, and is extremely 
irritable. Stupor sets in ; death may take place iu coma, or from ursemia. 

Subcutaneous Emphysema. Enlargement of or swelling of the 
surface, either local or general, may occur on account of air under- 
neath the skin. The primary seat of the swelling is in close proximity 
to the air passages, and occurs because of communication between 
them and the subcutaneous connective tissue. In ulcerations of the 
upper passages, as the larynx or trachea, it may occur, and in rupture 
of the lungs and pleura in cases where the latter is adherent, air will pass 
from the former into the connective tissue. From the seat of rupture, 
or in close proximity to it, as the starting-point, the swelling gradually 
spreads over the entire body. In a case of laryngeal phthisis under 
the writer's care it encircled the neck and spread uniformly over the 
anterior and posterior portion of the thorax. From thence it extended 
downward until it met a corresponding infiltration of the lymph spaces 
in the thighs due to serum. The distinction between oedematous 
swelling and subcutaneous emphysema could thus be made : the latter 
offered no resistance, did not pit on pressure, crackled under the finger, 
and was quite tender on pressure. Spontaneous pain was not present, 
but the weight of the body, in any position assumed pressing upon the 
part, caused pain. 

Connective-tissue Dystrophies. Swelling of the surface of the 
skin in irregular areas from changes in the connective-tissue are also 
seen in the so-called dystrophies. The dystrophy is usually due to a 
localized anomalous overgrowth of connective tissue probably of trophic 
origin. It can easily be distinguished from oedema by absence of the signs 
of oedema, or from local inflammatory swelling, by the absence of pain, 

7 



98 



GENERAL DIAGNOSIS. 



heat and redness. The swelling occurs on the arms and legs, usually 
on the outer aspects, and may occur in various portions of the trunk. 
In one of the writer's cases the swellings were periodical ; or rather, 
the persistent swellings increased in size at irregular intervals. 

Dercum and Henry have described them in cases in which the 
enlargement was thought by others to have been due to accumulations 
of fat. The patients presented marked subjective nervous phenomena, 
parsesthesias of all kinds, with flushings and sensations of sinking and 
depression. There were areas of anaesthesia, pain and tenderness in the 
nerve trunks. Pain preceded the advent of the swellings. 

Herpes zoster occurred in Dercum's case, and other symptoms of 
neuritis were marked. The irregularity of distribution of the swell- 
ings, their character and mode of development, the recurrence of neur- 
itis and the absence of perspiration distinguished this affection from 
lipomatosis or excess of fat. The patients were of a neurotic type, and 
usually mental impairment resulted in the course of the disease. The 
general nutrition failed, particularly as gastro-intestinal disorders ensued. 

Scleroderma. Scleroderma is a hyperplasia of the sub-connective 
tissue in which there is swelling with induration of the part. It is 
brawny. The term " hide-bound " is applied to this condition of the 
connective tissue and skin, on account of which the parts are almost 
immovable. There is marked stiffness and also pain. 

In localized scleroderma the skin has a waxy or dead-white appear- 
ance, is brawny and inelastic. There may be preliminary hyperemia 
of the skin. Subsequently pigmentation of the hypersemic area takes 
place, causing changes in color. Or the pigment may atrophy, causing 
leukoderma. The secretion of sweat is diminished, or entirely abolished. 
In the diffuse form the affection begins on the extremities or face, 
accompanied by a sense of stiffness or tension \ the skin is unusually 
hard and firm, and gradually a diffuse, brawny induration develops. 
The skin cannot be picked up iu folds. It may appear normal, but is 
generally very smooth, glossy, and dryer than usual. Scleroderma may be 
confined to a limb, or become universal. The appearance of the face is 
characteristic. It is expressionless, and the lips cannot be moved, while 
mastication is impossible ; then the hands become fixed and the fingers 
immobile on account of induration about the joints. It is thought to 
be due to a tropho-neurosis, or to fibrosis of the arteries of the skin, 
with connective-tissue overgrowth in the adjacent areas. 

Brawny Induration. CEdema must not be confounded with the 
brawny induration of the calves of the legs that is seen in scurvy, which is 
probably due to deep-seated hemorrhage, or to the affections between 
the periosteum and the bone which form chronic nodes. It must be 
remembered, however, that oedema of the ankles is very common in 
this affection. In a patient recently in the Presbyterian Hospital 
under the writer's care a brawny induration of the thigh, with painless 
swelling and stiffness of the leg, appeared to be due to syphilis. It 
disappeared rapidly under the use of iodide of potassium. The patient 
was syphilitic. 



THE DATA OBTAINED BY OBSERVATION. 



99 



Subcutaneous Nodules Distinctly Localized. Sarcomata. 
The subcutaneous uodules seen in these affections are rarely, if ever, con- 
founded with oedema or other swellings. In sarcoma the subcutaneous 
tumor becomes attached to the skin, and may change its color. It is 
usually secondary to sarcoma in some other organ of the body. When 
primary or secondary to organs in which there is normal pigmentation, 
as the eye, they become blue or bluish-black. On palpation the surface 
is rough and uneven if the tumors are in great number. 

Primary melanotic sarcomata of the skin can always be distinguished 
by their color. In both forms of sarcomata the general symptoms of 
this affection daily become more and more pronounced, and subcu- 
taneous hemorrhages are commonly associated with the local phe- 
nomena. 

Cysticercus Cellulose. The nature of the subcutaneous nodules 
of cysticercus are recognized by microscopic examination. They are 
usually associated with the larva? in other tissues, hence the patient will 
complain of great soreness and stiffness, and may on account thereof 
be helpless. In a case reported by Osier there was so much numbness 
and tingling in the extremities with general weakness that the patient 
was thought to have peripheral neuritis. 

Rheumatic Nodules. Subcutaneous nodules are seen in rheu- 
matism or in patients who have had frequent attacks of that disease. 
They are common in the young. They are particularly frequent in 
cases of rheumatic endocarditis. They may occur in large numbers, and 
vary from a small shot to a large pea. They are of fibrous structure. 
They are attached to the tendons and fascia?, particularly on the fingers, 
hands, and wrists, but may be found on the elbows, knees, the scapula, 
and the spines of the vertebrae. They may occur independently of an 
attack of rheumatism, or follow in its decline. 

The Temperature. Fever. In conditions of health the body tem- 
perature is maintained constantly at about 98.6° F. (37° C. ). This stability 
of temperature is due to the central regulating apparatus called the 
thermotaxic mechanism, which controls the production and the dissipa- 
tion of heat. Fever is a condition characterized by an increase of 
temperature with, usually, increased disintegration of nitrogenous tissue. 
The muscles and large glands, as is well known, are the chief seat of 
heat production. Both heat production and heat dissipation are believed 
to be under the control of the nervous system, either through the motor 
nerves or special nerves which pass with them to and from definite 
centres in the brain called heat centres. In conditions of disease this 
thermotaxic mechanism may be altered so that the normal temperature 
is increased or lessened. (1) There may be elevation of temperature 
from diminished dissipation of heat, though not necessarily increased 
nitrogenous disintegration and disordered function. Or, (2) there may 
be increased production of heat with diminished dissipation, hence the 
temperature will naturally be higher than if the increased heat produc- 
tion were accompanied by normal heat dissipation. (3) There may be 
increased heat production and at the same time increased heat dissipa- 
tion, in which case there would be the increased waste of fever with or 



100 



GENERAL DIAGNOSIS. 



without any elevation of temperature. (4) It is possible that heat dis- 
sipation may be greater than heat production, or that the thermotaxic 
mechanism may be disturbed so as to promote loss, in which case there 
will be subnormal temperature. 

Mode of Determination of Fever. The temperature of the 
body can be roughly estimated by the hand of the physician, but this 
method is open to many sources of error. The skin is at times hot 
and gives a deceptive sensation of considerable elevation of tempera- 
ture, whereas wheu tested by the thermometer the temperature is but 
slightly or not at all above normal. So, too, when the skin feels cold 
and clammy in phthisis and during a chill from any cause, the actual 
temperature of the body is decidedly above normal, and may be as high 
as 103° or 104°. To insure accuracy, therefore, it is now almost the 
universal custom to employ clinical thermometers. They are of a con- 
venient size and shape for insertion under the arm or into the mouth, 
rectum or vagina. The better ones are provided with an indestructible 
index, so that the mercury in the capillary tube remains stationary at 
the highest level to which it rose when the thermometer was in the 
mouth or axilla. When not provided with such an index the reading 
must be made when the thermometer is still in position. 

Thermometers vary in the accuracy with which they register tem- 
perature. The best ones are compared with an acknowledged standard 
and sold accompanied by a slip of paper which gives their fractional 
variations from the standard. When the exact temperature is a matter 
of great importance it should be taken in the rectum or vagina, as their 
temperature is more nearly that of the body. It is of advantage to take 
the temperature in the rectum in children or in patients who are coma- 
tose. This situation is also a good one to select when a bath is being 
administered. If possible, scybalous masses should be removed from 
the rectum. At least an incorrect reading may be obtained if the ther- 
mometer should happen to be plunged into the fseces: this must be 
guarded against. From motives of delicacy, however, the axilla is to 
be preferred to the rectum and vagina on all ordinary occasions. 
The temperature it records is somewhat less than a degree below that 
of the rectum. The temperature of the mouth is above that of the 
axilla and below that of the rectum. It has some advantages over 
that of the axilla, being more accessible and recording the tempera- 
ture more quickly and more accurately. Nevertheless, as the phy- 
sician's thermometer is carried from patient to patient, some place of 
taking the temperature should be selected which is less capable than 
the mouth of absorbing disease germs. The axilla is, therefore, by 
common consent the usual place of taking the temperature. Observe 
two precautions. (1) Before introducing the thermometer see that there 
is no undue moisture ; if there is, the axilla should be wiped dry, other- 
wise a lower than the true reading will be obtained. (2) See that the 
instrument is inserted into the armpit and does not project beyond the 
posterior fold, and that it is not caught in a fold of the undershirt or 
night-dress. After the thermometer is in position the arm should be 
brought gently across the chest and kept in that position until the 
instrument is withdrawn. The arm should not be held rigidly, as such 



THE DATA OBTAINED BY OBSERVATION. 101 



muscular action increases the hollow of the armpit and may keep the 
sides apart, instead of in contact, as they should be to make a correct 
reading. The length of time required to take the axillary temperature 
will depend upon the instrument used ; generally from five to eight 
minutes are required. Some very delicate thermometers register in 
one minute, but they are too fragile for ordinary use. If the index is 
in such a position that it can be seen it is proper to withdraw the ther- 
mometer when the mercury has ceased to rise for two minutes. 

The index, of course, must be shaken down to normal or slightly 
below normal before the thermometer is ready for use ; and the instru- 
ment must be carefully cleansed after use. These are hints which only 
students need to be reminded of. 

In children who are restless the temperature may be taken in the 
groin, as the folds of fat readily admit of completely enveloping the 
bulb of the thermometer. The height to which the mercury rises will 
correspond to the temperature in the axilla. The temperature of the 
urine corresponds exactly to that of the body if taken when freshly 
passed and during the act in males, before being received into a recep- 
tacle. Sometimes this method of securing the temperature is resorted 
to, particularly in patients who may act as malingerers and in whom 
it is desirable to have the temperature taken in the physician's 
presence. 

If the mouth is selected as the place in which the temperature is to be 
taken, care should be exercised that the thermometer is placed underneath 
the tongue, or along its side between it and the lower jaw, and retained 
in position by the lips of the patient. If the teeth are set firmly on the 
thermometer it may be broken, or, what is of still greater importance, it 
will be tilted out of position and a correct reading will not be obtained. 
The lips should be closed and breathing be carried on through the nostrils. 
Four to seven minutes is sufficient time to allow it to remain in posi- 
tion. The patient should not have taken ice or anything cold prior to 
the observation. 

Observations of the temperature should be made twice a day, in the 
morning and evening, and, as far as possible, at the same time on suc- 
cessive days. It is frequently desirable to have the temperature taken 
every two or three hours, and sometimes at more frequent intervals. 

In obscure cases the observations should be repeated at night as well 
as during the day. In this manner the presence of unsuspected tuber- 
culosis may be revealed, or the occurrence of suppuration in some por- 
tion of the body, the seat of an obscure process, definitely determined. 
It should not be forgotten, however, that the temperature may be taken 
too frequently for the patient's good, the disturbance of his needed rest 
being distinctly harmful. 

As the general range of temperature and its diurnal variations are of 
more importance than the absolute temperature at any one time, ther- 
mometers not perfectly accurate in their reading are still good enough 
for clinical and therapeutic purposes. 

Physiological Variations of Temperature. The tempera- 
ture is subject to physiological variations. 1. It rises from seven or 
eight in the morning until seven or eight in the evening, at which time 



102 



GENERAL DIAGNOSIS. 



it reaches its maximum. It then begins slowly to fall, reaching its 
lowest point in the early hours of the morning, between two and four. 
This diurnal fluctuation does not usually amount to more than a degree. 
2. Exercise, etc. Violent exertion raises the temperature, and so does 
a heated atmosphere, cold having a contrary effect. 3. Age. In infants 
and young children, up to puberty, the temperature has a somewhat 
higher range, and is subject to greater variations than at a later period. 
In very old persons the temperature may be subnormal. The normal 
axillary temperature of adults is 98.6°F. The period in the twenty- 
four hours in which the temperature is at its lowest ebb is from 12 p.m. 
to 4 A.M. It may then be subnormal. The writer has known an over- 
cautious parent have this physiological fall made the subject of meddle- 
some observation and ill-judged treatment. 

Pathological Variations of Temperature. An elevation of 
temperature above the normal not to be accounted for by external heat or 
severe exhaustion may be considered febrile, and is pathological. The 
range of febrile temperature varies from above normal to 105° or 106° 
in ordinary cases. A range above 106° may occur, but is not usually 
compatible with life. Certain terms have been applied to various 
degrees of temperature to indicate in a general way the degree of fever. 



Below 


1 35° 
t 36 


Cent. 




95.0° Fahr. 
96.8 


Very low, or collapse temperature. 


About 


36^ 


Cent. 




97.7° Fahr. 


Subnormal temperature. 


normal 


37 






98.6 


Normal temperature. 




t 37 V 2 


Cent. 




99.5° Fabr. 


Slightly above normal, or sub-febrile temperatures 


About - 


38 
I 38^ 






100.4 
101.3 




About 


\ 39 
I 39^ 


Cent. 




102.2° Fabr. 
103.1 


Moderately febrile temperature. 


About 


f 40 


Cent. 




104.0° Fabr. 


Highly febrile temperature. 








104.9 




Above 


41 


Cent. 




105.8° Fahr. 


Hyperpyretic temperature. 



(From Fjnlayson.) 



The Degree of Danger. In general the danger to the patient 
increases with the height of the fever, but the duration of the high fever 
modifies this greatly. A temperature of 106° on the second or third 
day of an acute lobar pneumonia is not rare, such cases frequently 
ending in recovery, while a temperature of 105° in the second or third 
week of typhoid fever is of much graver significance. Da Costa has 
reported a case of cerebral rheumatism in which the axillary tempera- 
ture reached 110°, yet the patient recovered. In the case of injury of 
the spine reported by Teale the extraordinary temperature of 122° was 
recorded, and the temperature range for days was between 112° and 
114°. The patient recovered. 

The Types of Fever. Fevers are divided in accordance with the 
character of their range into certain definite types. The types may be 
indicative of special processes. It is certain that the recognition of a 
particular type forms a positive aid to diagnosis. The fever that con- 
tinues for more than two days, in which the difference between the daily 
maximum and minimum of temperature is less than 2° is known as 



THE DATA OBTAINED BY OBSERVATION. 



103 



continued fever. (See Fig. 8.) The fever existing more than two days, 
in which the daily difference is greater than 2° is known as remittent 
fever. Further, a fever in which there is a rise of temperature fol- 
lowed by a fall to or below the normal, occurring at least once during 



Fig. 




the twenty-four hours, is known as an intermittent fever. The par- 
oxysms may occur daily every second or third day, or once a week. 
When the paroxysms occur daily the intermittent is of quotidian type 



Fig. 4. 




(see Figs. 3 and 5) ; every second day, tertian type, one day interven- 
ing without fever (see Fig. 4); every third day, quartan type, two 
apyretic days intervening. 



104 



GENERAL DIAGNOSIS. 



The Course of the Fever. Fevers have frequently a definite 
course, known as (1) the initial stage ; (2) the fastigium ; (3) the period 
of defervescence. During the initial stage the temperature rises higher 
each hour, or if extended over days, each day, than the precediug hour 
or day — in this latter instance interrupted by the daily fluctuations. 
The stage may last from a few hours, as in a paroxysm of intermit- 
tent fever, to four or five days, as in typhoid fever. In this stage we 
have a chill such as characterizes the onset of an intermittent fever, 
or the recurrent chills or chilliness with headache and backache that 
attend the first four or five days of typhoid fever. During this stage, 
also, the heat dissipation from the cutaneous surface is diminished, and 
heat dissipation generally is less. When the hand is placed upon the 
patient the surface will be found to be cool, whereas the temperature 
in the mouth or rectum will be found to be far above normal. The 
patient complains of the coldness or chilliness, and the low temperature 
of the surface is indicated by the shrunken hand, the pallid, pinched 
face. The peripheral arteries are contracted, and hence cause diminu- 
tion in the amount of blood to warm the skin and to compensate for 
the loss by radiation and conduction. This peripheral contraction 
is the cause of the chilliness and the fall in the temperature of the 
skin. 

During the second period of the course of pyrexia — the fastigium 
— the temperature of the body attains the highest point, and remains 
almost stationary, or may vary but a degree or two betAveen maximum 
and minimum. It may last a few hours or from two days to three or 
more weeks, during which time it may oscillate to the maximum point 
of the first day. The temperature of the surface of the body is about 
the same as that of the deep parts, particularly in cases of pneumonia, 
measles, and scarlet fever. In typhoid fever, acute rheumatism, and 
phthisis, during this period, there may be a difference in the external 
temperature and the temperature taken in the cavities, as the mouth or 
rectum. More or less antagonism between heat production and heat 
loss exists under these circumstances. The latter may be greater than 
the former, if the skin perspires freely as in rheumatism. The tem- 
perature then remaining high indicates that the production of heat 
must be proportionately increased, and hence far greater than in cases 
in which the external and internal temperature are nearly the same. 
(See Fig. 6 : the fastigium here occurs in the first three days. In Fig. 
9 the fastigium lasts until crisis.) 

In the period of defervescence the temperature falls to the normal. In 
this period an attempt is made by the economy to return to a physio- 
logical state, in which heat production and heat loss are evenly balanced. 
The state of pyrexia pathologically has come to au end. The termina- 
tion may be by crisis. (See Figs. 4 and 9.) When this takes place 
the perturbation of the thermotaxic mechanism must be very great, but 
at once the normal state is resumed. In other cases the termination is 
by lysis — the temperature falls a degree or two each day until the normal 
is reached. (See chart of Typhoid Fever.) It seems that the thermo- 
taxic mechanism of health is restored with difficulty. In some cases, 
in the period of defervescence the aberrations are sometimes very 



THE DATA OBTAINED BY OBSERVATION. 



105 



remarkable. It seems as if the therm otaxic mechanism which controls 
heat loss was in a convulsive state. The temperature rises and falls 
irregularly, gradually assuming the normal position only as the strength 
of the patient increases. 

The Mode of Onset of the Initial Stage. The onset may be 
sudden or gradual. 1. The sudden onset occurs in acute diseases, as 
tonsillitis, pneumonia, and gastro-intestinal disorders of children, in 
erysipelas and in intermittent fever. Within a few hours the maxi- 
mum of temperature is reached. (See Fig. 9.) 2. The mode of onset 
may be gradual. The initial stage is prolonged under these circum- 
stances, as in cases of typhoid fever. (See chart of Typhoid Fever.) 

The Mode of Decline in the Period of Defervescence. A 
sudden fall of temperature at the termination of a disease is known as 
crisis, which is also characterized by copious perspiration, a ''critical 
sweat/' or by the passage of a large quantity of urine, and sometimes 
by several large liquid stools. The pulse rate and respirations fall cor- 
respondingly with the temperature. (See Fig. 9.) 

The defervescence may, however, occupy several days, in which case 
it is said to occur by lysis. In this case the sweating is less marked, 
but may occur through several days. The slowing of the pulse and 
respiration likewise occur more gradually. (See chart of Typhoid Fever.) 

Diseases that are of sudden onset usually terminate with sudden de- 
cline, and correspondingly, in diseases in which the onset is prolonged 
the decline is also prolonged. Many cases in which the natural termi- 
nation is by crisis may terminate by lysis. This change is usually due 
to complication. (See Fig. 6.) In measles, pneumonia is usually the 
causal complication, while in pneumonia it is empyema or endo- 
carditis. 

The Daily Kange of the Prolonged Initial Stage, and 
the Fastigium. The daily range of the temperature in fever generally 
corresponds to the normal variations. That is, the temperature is low r er 
in the eveniug than in the morning. The difference in the daily range 
varies in the different types of fever — generally, as previously noted, 
the continued fevers having a smaller difference between morning and 
evening temperature, the intermitting fevers a larger difference between 
the two. 

Sometimes there is inversion of the normal range. The evening tem- 
perature is lower than the morning ; although a rare condition, this is of 
serious import. It is seen in the course of typhoid fever in the more 
severe cases, and occasionally in tuberculosis. 

Recrudescence. After the temperature falls to the normal, in 
many cases fever is again renewed. This may occur from a number of 
causes. It may be from perturbation of the nervous system on account 
of excitement, over-exertion, and the loss of sleep, or from indigestion. 
Slight aberrations, which in health would not modify the temperature, 
in illness cause pronounced oscillations. Recrudescence, further, may be 
produced by a relapse. After the afebrile period following typhoid 
fever, for instance, the temperature may rise and a full recurrence of the 
disease take place. (This occurrence is well seen in the temperature 
charts accompanying the article on Typhoid Fever.) 



106 



GENERAL DIAGNOSIS. 



The Symptoms of Fever. Pyrexia, or increased temperature, is 
not the only evidence of fever. The production of heat within the body 
is not alone due to increased tissue change. It may be due to increased 
oxidation of sugar, for instance, which is part of the substance of the 
body. Physiologists have found that a high temperature may take 
place, and yet the quantity of urea and of carbonic acid which is dis- 
charged may not be as great as that discharged by a healthy person 
who is taking active exercise or who has eaten a large meal. It must 
be remembered, therefore, that it is not heat production alone, but 
alterations of heat regulation, which cause pyrexia and its phenomena. 

Wasting. Wasting of the body is a striking feature of fever. 
There is no doubt that even in fever of moderate duration great wast- 
ing of the solid structures takes place. At the same time the blood 
wastes (see observations of Thayer), and the various fluids of the body 
are also diminished ; hence the disorders due to diminished secretion of 
glands are prominent in the course of fever. Thirst, diminution of secre- 
tions in the gastro-intestinal tract, on account of which loss of appetite 
and indigestion and constipation arise, all indicate the wasting of the 
fluids. Scanty urine of high color and specific gravity is due to the 
same cause. 

The Pulse Hate. Acceleration of the pulse is one of the phe- 
nomena that attend pyrexia. While the increased pulse is in all proba- 
bility a result of the increase in temperature, and is the usual occur- 
rence, other circumstances will cause a change in the pulse rate in 
fever patients. Thus, in basilar meningitis, although there may be a 
high fever, the pulse is not increased. On the other hand, some cases 
which usually give rise to fever, as diphtheria and peritonitis, may be 
afebrile, and yet the pulse is very much accelerated. 

While there is acceleration of the heart's action, the rapidity with 
which the blood flows in fever and the arterial tension do not bear a due 
proportion to the acceleration. The true febrile pulse is not dicrotic. In 
the early stages of fever the pulse is large and hard, the arterial tension is 
high, and the vessels full. In the later stages arterial relaxation takes 
place, and with low pressure the pulse becomes soft and feeble, and often 
small. The pulse is rapid, and dicrotism, or even hyper-dicrotism now 
becomes a prominent feature. The heart beating rapidly empties itself 
incompletely and discharges less rather than more blood into the arteries. 
The impairment of the cardiac beats is no doubt due to the degenera- 
tions which are liable to take place on account of the high temperature, 
and is not dependent upon any special febrile affection. Such changes 
also take place in the glands, particularly the liver and kidneys, and are 
known as parenchymatous degenerations or cloudy swelling. On ac- 
count of these changes in the cardiac muscle, in the later stages of fever, 
thrombi may develop, and death takes place from heart-clot. 

Respiration Increased. The respirations are increased in fever, 
probably because of the close dependence of the regulating centres of 
respiration on that of the heart. The heated blood acts as a stimulant 
to the respiratory centre. As proof of this the hurried respiration of 
pneumonia ceases as soon as the temperature falls, notwithstanding the 
affected part of the lung remains hepatized. 



THE DATA OBTAINED BY OBSERVATION. 



107 



Cerebral Symptoms. Delirium and other nervous symptoms may 
attend fever. They are not dependent upon the increased temperature 
of the blood alone. No relation appears to exist between the intensity 
of the fever and the severity of the delirium. In relapsing fever a 
temperature of 106° occurs with the mind clear. In certain cases of 
typhoid fever a temperature of 103° is attended with marked delirium. 

If fever persists for a short time, a low asthenic state may develop. 
Because the symptoms resemble those of typhus fever, the term typhoid 
is applied to them, and the condition about to be described has been 
known as the typhoid state. The expression is dull and heavy, the 
capillaries of the face are congested. There is stupor and sluggishness 
of mental processes, so that the patient is slow in answering questions. 
The stupor is attended with low muttering delirium, and may be fol- 
lowed by complete unconsciousness. The pupils are contracted, the eye 
heavy and dull. The patient is so prostrated that he slips down into 
the bed from the pillow. There is marked subsultus tendinum. The 
tongue, if protruded, comes out slowly and is tremulous. It is dry and 
brown, and the mouth and teeth are covered with sordes. The sensi- 
bilities are blunted so that food and drink are not asked for, or particu- 
larly relished if given. Involuntary discharges take place from the 
rectum and bladder, and the incontinence from retention of the urine 
arises. The pulse is small, feeble, and dicrotic, the heart sounds are 
weak and feeble. The first sound become short and snappy like the 
second, or may be absent entirely. Venous stases take place in the 
dependent portions, particularly in the back of the lungs. As oedema 
or hypostatic congestion advances the breathing becomes shorter and 
labored. More or less cyanosis then creeps over the general surface. 
The urine becomes more and more scanty and high-colored, contains 
albumin, and there may be some blood. 

The typhoid state may continue for many days, or even last two or 
three weeks, although not in so advanced a degree as has just been de- 
scribed. It is more likely to supervene when there is excessively high 
temperature, but it also occurs in the course of an illness with prolonged 
temperature of moderate degree — that is, of 103° F. Although in all 
probability it is due to the direct effects of heat upon the nerve centres 
and the organs of the body, yet there are cases in which the tempera- 
ture is not high, and yet all the symptoms of the typhoid state super- 
vene. While the typhoid state is common to typhoid fever, it occurs 
also in pneumonia and septicemia, and may be seen in most typical 
form in other conditions in which fever is not a pronounced symptom ; 
thus, in urosmia, in the later stages of softening of the brain, in paresis, 
or in allied nervous diseases, the symptoms of the typhoid state are 
most striking. In this class of cases it certainly cannot be attributed 
to the fever, and in all probability is due to the depressing effect on 
the nervous system of material which should be excreted from the body, 
a view which has been advocated by Murchison, Flint, and others. 

Ataxia, or the ataxic state, in fever is a condition the opposite of 
the adynamic, or typhoid state. In the latter there is weakness, while in 
the former there is exhibition of strength. In the latter the nerve 
centres and the vital processes are depressed ; in the former they are 



108 



GENERAL DIAGNOSIS. 



stimulated. Ataxia as an exhibition of strength is characterized by a 
strong pulse, by active violent delirium, so that it is almost impossible 
to keep the patient in bed ; by evidence of great muscular strength. The 
face is flushed, color bright red, the eyes injected, bright, and active. 
The tongue is furred, but is not necessarily dry or brown. The delirium 
may be constant or be pronounced at intervals, and is often maniacal in 
character. The temperature of the body is high, and a sensation of in- 
tense heat when the hand is placed on the skin of the trunk is given off. 
The patient may complain of a bursting, intense headache. If the ataxic 
state is not controlled after a few days, or at the most a week, the 
patient becomes exhausted and lapses into stupor, which may proceed 
to coma. In some forms, particularly in children, convulsions may 
take place with excessively high temperature followed by coma. The 
same exhibition of strength is shown. The ataxia is seen notably in 
scarlet fever, "cerebral" pneumonia, and forms of typhoid fever. The 
peculiar behavior of the temperature and nervous symptoms in this 
affection and in apex pneumonia, or so-called pneumonia of the cerebral 
type, have led observers to mistake cases for those of actual cerebral dis- 
ease. Frequently such cases have been admitted into insane asylums 
for supposed mania. Cases of this character have not been appreciated, 
an insufficient force of nurses being placed over them, with the result 
that in a number of instances the patients have jumped from windows or 
escaped from the room and gone out on the streets. 

Just as in the adynamic cases it is difficult to determine the exact 
cause of the extreme perturbation of the nervous system, in febrile 
ataxia it is easy to say that it is due to a high temperature acting on 
nerve centres ; but on the other hand, it is just as easy to say that it is 
due to a poison, a toxin from infection, which has created the tempera- 
ture on account of which the nervous symptoms have ensued. 

In addition to the increase of temperature as registered by the ther- 
mometer, the presence of fever may also be recognized by flushing of the 
face. This may be general or local. The local flush of phthisis and 
of pneumonia have previously been referred to. Sweating is a condi- 
tion habitual in some fevers. It may occur throughout the course of the 
disease or at certain stages only in the course of tuberculosis, as the early 
morning or night sweats testify. In such cases it is cold and clammy. 
The same sweatings are common in the fever of deep-seated suppuration 
and in disease of the bones. Sweating in defervescence marks the occur- 
rence of crisis. Dryness and pungency of the skin more commonly, how- 
ever, occur in fever. In former times the sense of heat was given different 
attributes which were said to be distinctive of various affections. Thus 
the sensation to the hand of the heat in typhus fever was said to be 
peculiar and characteristic. The degree of fever was also indicated by 
touch. The thermometer has now displaced this method of reckoning 
temperature. 

Headache and Pain in the Back occur in the acute specific 
fevers in the initial stage. One or both are nearly always present, but in 
their most pronounced form in different affections they have diagnostic 
significance. Thus pain in the back is more pronounced in tonsillitis and 
smallpox, severe headache in cerebro-spinal meningitis, and protracted 
throbbing headache in typhoid fever. 



THE DATA OBTAINED BY OBSERVATION. 109 

Subnormal Temperature. A temperature below the normal 
may occur independently of fever, but it usually follows the occurrence 
of pyrexia. It occurs independently in the course of wasting diseases, 
as cancer, in starvation, at times in anaemia. It is seen habitually in 
myxoedema and occasionally in diabetes, in certain forms of tuber- 
culosis it is seen to extend over a long period of time, as in tuberculous 
peritonitis. (See chart under Tubercular Peritonitis.) Sometimes the 
subnormal temperature may occur suddenly, to be followed by a sub- 
sequent increase in the temperature range. Sudden fall of temperature 

Fig. 5. 





















- 








E 








E 




E 


103 - 














































f 












T ■ 






















I02_ 






— L 












_.I . 
































-it- 








3 : 






















IOI- 










i- 




■*■ 




3 






























1 






: 


































4 






L 




- 






















ioo c - 


X 






—4- 






■\ 




























1 












\ 


























99- 






































































| 
































A 


















98- 




















1 




































































































97- 


















n 






r 
























































9 6°- 


















— \ 










































- 




























































95°- 










4 






































































94- 










4- 














































































1 


I 








H — 


- 


















93°- 




















4- 












V 




























4- 




















9 2°_ 




















-f— 














































































T 




















91! 




















1 





















Subnormal temperature. Oscillations in hepatic intermitting fever with jaundice. Catarrh of 
ducts, with diffused hepatitis. G. W., aged 60. Philadelphia Hospital, 1877. 

below the normal may occur in shock, or from hemorrhage from any 
cause. It may take place from disturbance of the central nerve centres, 
as from apoplexy, thrombosis, or embolism of the brain ; either from 
shock or from disturbance of the thermotaxic mechanism. It is char- 
acteristic in cholera. In the course of organic heart disease sudden 
pulmonary embolism is also attended by fall of temperature below the 
normal. In many of these instances the temperature will rise (reaction) 
after the shock, if the latter is not too profound. This is notably so in 
apoplexy and in the other conditions indicated in which the presence of an 



110 GENERAL DIAGNOSIS. 

embolus or thrombus, or the local condition on account of which hemor- 
rhage took place (softening) may act as a source of irritation. In apo- 
plexy the rise in temperature will occur either from central disturbance of 
the thermic mechanism or from secondary inflammation about the clot. 
The subnormal temperature that occurs in the course of fever may be 
due to an accident or complication, as hemorrhage in disease of the lungs, 
or in typhoid fever, or the suddeu occurrence of perforation of the intestine 
in the latter condition. At the usual period of the termination of acute 
disease it attends the crisis. More or less collapse usually attends the 
pathological fall of temperature below the normal. While such fall is 
the result of accident in many of the diseases mentioned, in other dis- 
eases the fall of temperature appears to be part of the process. 

The chart (Fig. 5) represents the effect of a local process in the largest 
gland of the body upon the general temperature. It is possibly a sep- 
tic temperature, although the observation was made before the days of 
bacteriological research. The extreme low temperature is remarkable. 

The Diagnostic Significance of Fever. Its Clinical Causes. 
The presence of fever is of diagnostic importance. It excludes hysteria 
at once, usually, and generally the feigning of disease. It indicates that 
one of several morbid processes is present. The morbid processes which 
give rise to fever are : First, infectious diseases, acute and chronic. Second, 
inflammations, which may be coufined to the mucous membranes, or to 
the surface of the skin, or involve the various viscera, or the membranes 
in relation with the viscera. The fever under these circumstances may be 
due to irritation of the heat centres or the thermotaxic mechanism by 
ptomaines, or chemical principles derived from the inflamed parts. The 
inflammation, on the other hand, may be suppurative or septic. The 
fever is then higher than in the former condition, and is most marked 
when pus is closely confined. On account of the local septic process, 
toxins, or a chemical poison of some kind, are absorbed. The purulent 
inflammation may be seated in the connective tissue or bones, the brain, 
the liver or kidney, or the serous membranes. When the local inflamma- 
tion sets up intense infection of the system by emboli the formation 
of metastatic abscesses takes place. The fever that attends the pro- 
cess becomes of a peculiar intermittent character, and is known as 
pysemic. Third, in certain intoxications of the system, as from 
ptomaines in gastro-intestinal disorder, or affections of the liver, and 
in poisoning from various causes, a fever may be set up. The same 
mechanism attends the process. Fourth, fever may be of central origin, 
from disease of the brain involving the centres controlling heat, or from 
disease in proximity to the heat centres. In cases of brain tumor, in cases 
of apoplexy, and of thrombosis, fever may arise. The centres may also 
be irritated by direct exposure to external heat alone, or possibly by 
poisons generated within the system on account of the heat, as in sun- 
stroke. Fifth, an irregular form of fever is seen in anaemia and in 
starvation ; while such form is of clinical significance, pathologically it 
seems to be of the same cause as others mentioned. Sixth, a pronounced 
peripheral irritation or sensation of pain, reflexly altering the thermo- 
toxic mechanism, will produce fever. Hence, in iritis or orchitis a fever 



THE DATA OBTAINED BY OBSERVATION. 



Ill 



arises out of all proportion to the local inflammation. Finally, cases of 
continued fever exist that have not thus far been classified. One of 
the nurses of the Presbyterian Hospital with a continued temperature 
from 100° to 103° was under my care for two months. No general 
or local condition could account for it. The patient was emaciated. 
She had had two years of very hard work. Although fever kept up, the 
appetite was good. Careful feeding of an abundance of food, with rest 
for many weeks, caused the temperature to fall to normal with complete 
recovery. I looked upon it as a nervous fever ; an expression of ex- 
haustion. Fagge refers to such case. (See article on Fever.) 

The Significance of the Initial Stage. 1. In the initial stage 
of fever sudden rise of temperature to a high degree from a condition 
of apparent health is against any of the infectious diseases, except 
scarlet fever. It is of more frequent occurrence in acute gastric or 
gastro-intestinal catarrh in children than in any other condition in the 
same class of patients. It may be due to a pneumonia, and is particu- 
larly significant if a pronounced rigor attends the rise in adults. In 
children convulsions may replace the chill. The sudden rise may be 
due to malaria, in which case it is also accompanied by a chill and fol- 
lowed by free sweating. It may also be due to affections of the throat, 
to follicular or phlegmonous inflammation of the tonsils. The throat 
must always be examined in cases of sudden high temperature. 

In children if pain attends any inflammatory affection, the temper- 
ature will rise to a greater height than the local process would warrant. 
This is the case with suppurative inflammation of the middle ear. This 
organ must be examined in order to exclude the process when the tem- 
perature rises rapidly. In osteomyelitis and in mastoid abscess the 
same active febrile reaction will take place. The associate signs point 
to the true nature of the affection, although it must be confessed that 
in both, the symptoms are often obscure in the beginning. 

2. In typhoid fever the temperature rises in a characteristic way. 
The temperature ascends by successive evening rises, followed by morn- 
ing remissions, until it reaches the maximum at about the end of the 
first week. 

The Significance of the Fastigium. In typhoid fever the 
course of the fastigium is of characteristic significance. From the end 
of the first, throughout the second week, and sometimes longer, the fever 
is of the coutinued type. Subsequently during the third week or later, 
morning remissions set in, the temperature for a time still rising to the 
former height in the evening. Then the morning remissions become more 
decided, the temperature not rising as high in the evening, and so gradu- 
ally the temperature sinks to and below normal. This course of the 
temperature in typhoid fever is very far from being invariable; it is 
modified by indiscretions on the part of the patient or his attendants, 
and by the necessities of antipyretic or other treatment ; nevertheless, 
the gradual onset of the fever and its long duration are sufficiently 
common to make them of great value in diagnosis, as, with the excep- 
tion of tuberculosis, there is hardly any other disease in which a con- 
tinued fever exists for two or three weeks apart from local inflammation 
or suppuration. 



112 



GENERAL DIAGNOSIS. 



The Significance of Defervescence. A continuance of the 
fever, the persistence of the fastigium beyond the usual period, is usually 
significant of the occurrence of a complication. Iu measles the com- 
plication is usually pneumonia. This may take place after the disease 
has developed, aud on account of it the temperature may rise higher 
than usual. In scarlatina it may indicate acute nephritis, or inflamma- 
tion of any of the serous membranes, particularly the pericardium or 
endocardium. Persistence of the fastigium of typhoid fever after the 
period at which it should decline, if the patient is well nursed and 
properly fed, usually indicates the occurrence of an inflammatory com- 
plication or the development of tuberculosis. In the latter condition 
the fever is more likely to develop during the afebrile period, the 
convalescence. Of the inflammatory complications, phlebitis and 
glandular inflammations are likely to cause persistence of fever after 
the normal period. 

Fig. 6. 





M 


E 


M E 




E 


VI E 11 


E 


M 


E 


M 


E 


M 


E 




E 




E 


1 E 


M 


6 




E 


M 


E 




E 


M 


E 




E 




E 




E 


M 


E 


M 


E 








































































































































































































































































































































































































104- 






































































































































































































































X 




































£ 


























0- 












































































103- 




















— 


— 




























































! 










































































1 
















v. 
























































































































































































102- 




























































i 


















































































































































































































. 


















































■ 


























































101— 








— 






























































1 






































































































\ 


/ 




































































































































































































100- 
























- 


























































1 




f 














f 




\\/ 


\ 






















A 


X 




























































































































































































































99- 


















































































































- 






















































































4- 
































































































Pnlse 






. 






j 
















°v 






















Date 


2/14 


15 


1G 


17 


18 


19 


20 


21 


22 


23 


24 


25 


2fi 


27 


28 


1 




3 


4 




c 



Scarlet fever. Modification of temperature by complications. Nephritis on the ninth day. 



The Significance of a Sudden Fall or of Subnormal Tem- 
perature. The occurrence of the normal or subnormal temperature in 
a person who has previously had high fever signifies the occurrence of 
crisis if the time for that event has arrived, as in pneumonia ; or of a 
grave complication, causing shock to the system. In typhoid fever this 
unusual drop in the temperature will take place if there has been a hem- 
orrhage from the bowels, or perforation, or the occurrence of peritonitis. 
It must not be confounded with the sudden falls of temperature that 
occurinthe typhoid feverof children, corresponding to the onset of conva- 
lescence. These occur earlier in the period of the disease than with adults. 

The Diagnostic Significance of the Type of the Fever. 
Intermittent Fever. The temperature range has been observed for a 
number of days and an intermittent type of fever ascertained to be 
present. The representative of the type is seen in malaria, but it is 
simulated by a number of conditions: (1) In certain cases of typhoid 



THE DATA OBTAINED BY OBSERVATION. 



113 



fever and of relapsing fever the type is intermitting or paroxysmal. 
The same type of fever is seen (2) in suppuration, particularly if the 
pus is confined; (3) in ulcerative endocarditis; (4) in tuberculosis, a. 
This may occur in tuberculosis in the earlier stages. The primary seat 

Fig. 7. 




Intermitting fever of tuberculosis. 

of the lesion may be in the lungs, in the bones, or in the glands, b. In 
pulmonary tuberculosis, after the formation of a cavity, intermitting 
fever is of common occurrence. It is then of septic origin due to the 
septic influence of the necrosed tissue and products of putrefaction in 
the cavity. (See Fig. 7.) 

Fig. 8. 





E 






M E 




E 


M E 


M E 


M E 


M E 




E 




E 




E i 


E 


M ! E 








E 


1 E 


t E 


M 




E 




E 




E 






i 


A 






8 


k 




r 
















$ 









































r 


r 








1 








r 


1 


k 












A 




1 




V 


A ; 
=\ 




A 











Continued fever of tuberculosis. 



(5) In lymphadenoma and anaemia the fever is at times paroxysmal. 
(6) In syphilis the same type is often seen. It may be noted (a) in the 
initial fever ; (6) in the tertiary periods of the disease where gummata have 
formed or other forms of visceral syphilis have developed. (7) Urinary 
intermitting fever is the form which usually occurs after the passage of a 

8 



114 



GENERAL DIAGNOSIS. 



catheter or sound, but it may also occur when there is suppuration in 
the genito-urinary tract. (8) Hepatic intermitting fever is a form of 
frequent occurrence and ot great diagnostic importance. It may be 
due to the presence (a) of gall-stones somewhere in the biliary ducts, 
usually with obstruction ; (6) to the presence of suppuration in the canal 
with or without obstruction ; (c) to the obstruction of the biliary pas- 
sages by external pressure without the occurrence of suppuration ; (d) 
inflammatory affections of the liver, as abscess, and forms of cirrhosis. 
Rarely it occurs in rapidly growing cancer. (See Fig. 5.) (9) Inter- 
mitting fever may also occur from the prolonged use of morphia. 

Fig. 9. 





M 


E 


M E 


M 


E 


M 


E 


M 


: m 


E 


M 


E 


— 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


105 
























































































































rf 






















































104— 




















/- 
































































































103 














P 




















































4 




3 














































0- 






















f 




































102- 


















1 




























"I- 




































































101- 




















































































































106- 














































































































































































99- 






































































































1 














•98- 




















































































r 


























































































Pulse 


























































Date 






ts 




GO 




O 






OS 




US 









Pneumonia. Sudden rise. Termination by crisis. Pseudo-crisis also seen. 



Of the above-mentioned varieties of paroxysmal or intermitting 
fever, those of most common occurrence are due to suppuration, pyaemia, 
to ulcerative endocarditis, to tuberculosis, and to hepatic disorder. In 
this class of cases, in addition to the paroxysmal rise in temperature, 
rigors and sweating frequently precede and follow the paroxysm, as in 
cases of intermittent fever. The diagnosis from true intermittent fever 
can be established at once by an examination of the blood, which re- 
veals in the latter the plasmodia of Laveran. 

Remittent fever. Fever of a remittent type occurs in many of the 
conditions in which intermittent fever is present. It is characteristic 
of one of the forms of malaria. It is most frequently encountered in 
tuberculosis of the lungs. The remissions usually occur in the morn- 
ings, but the order may be reversed. The same type of fever is met 
with in puerperal fever, pyaemia, and septicaemia, and in local suppu- 
rations, such as abscess of the liver and empyema. A continued fever 
may be made to resemble a remittent by antipyretic treatment, on 



THE DATA OBTAINED BY OBSERVATION. 



115 



account of which abnormal drops in the temperature take place. 
Remissions characterize the decline of the continued fevers, particularly 
typhoid, during the period of lysis. 

Continued fever. Contiuued fever is met with in lobar pneumonia, 
typhoid fever, typhus fever, erysipelas, and tuberculosis of the lungs 
at times. In acute lobar pueumonia the temperature rises rapidly, 
and in a few hours from the initial chill reaches 103° or 105°. The 
morning and evening temperature varies but little, usually not more than 
one or two degrees until a crisis occurs, in from four to eight days. 
The temperature then falls to or slightly below normal, and does not 
again rise. (See Fig. 9.) 

A marked remission in the fever sometimes occurs on the fourth day 
before the actual crisis ; the temperature falls to 100°, and again rises 
to 103° or 104° ; remains at that level for twenty-four or forty-eight 
hours, when the true crisis occurs. The fall of temperature or defer- 
vescence (crisis) may occur in a few hours. 

Diagnostic Significance depending upon Age and Sex. 
The significance of a high febrile change in children is not so great 
as in adults. That is, the high temperature is not so important, inas- 
much as children are liable to have sudden rises of temperature to a 
great height ; and a higher temperature may persist for some time 
without the effects upon the tissues which occur in adults. In women 
of nervous temperament the temperature is also likely to rise to a great 
height without marked cause or serious result. 

The General Musculature. The state of the muscles must 
always be learned. In the discussion on emaciation it was referred to. 
A few words more seem necessary. It must be remembered that a person 
can be obese and yet have poor muscular development, or have little fat 
and fair muscle. General lack of muscular development, or muscular 
weakness, is a most important sign of malnutrition, and when recognized 
will explain the nature of many symptoms. Weakness of the muscles 
of the spine, with resulting curvature, or inability to keep in the erect 
posture, is sufficient cause for the occurrence of neuralgic pains in the 
course of related nerve trunks, and for the displacement of organs 
within the thorax or abdomen, on account of which functional disturb- 
ance has arisen. Various uterine displacements and functional disorders 
may be mitigated by toning up the nutrition of the muscles of the trunk. 
Forms of indigestion, sluggishness of secretions, particularly of the 
bowels, follow in the wake of debilitated muscle and pass away as such 
muscles gain tone. It may be that the indigestion has not taken place 
because the muscles are weak, although in a measure there is relation 
between them ; but the weak, flabby muscles are pronounced indications 
of a state of the system which certainly does cause the development of 
such conditions. The observation of muscular deficiency leads to correct 
lines of treatment. Atrophy occurs because of disuse, because of sedentary 
occupation, or a life of ease and luxury with improper nutrition. It is 
sure to follow improper assimilation in its most prominent form, as 
seen in anorexia nervosa. 



116 



GENERAL DIAGNOSIS. 



General Abnormal Vital Conditions. Fits ; or Seizures ; 
Collapse ; Coma. General observation of the exterior at once re- 
veals to us the occurrence of fits, should they have taken place, or of 
alterations of the consciousness of the individual. The two often go 
hand-in-hand, but in some instances, as in fainting fits, consciousness is 
not lost. The following indicate the forms of each that may be met 
with. Only those are mentioned which occur instantaneously, and for 
which the doctor is called. For their symptomatology and diagnosis 
the appropriate sections on special diagnosis must be consulted. 

I. Fits with unconsciousness : 

1. Syncope. The face is pale but calm, the pulse feeble or impercep- 
tible, the extremities cool, nausea or hurried breathing may precede. 
The breathing is quiet in the attack. The pupils respond to light. No 
pain. (See Heart Disease.) 

2. Apoplexy. (Spasm is sometimes associated.) Head pain, congested 
face, hemiplegia, facial palsies, pupils irregular and irresponsive, cornea 
not sensitive, incontinence of urine ; pulse strong, full ; arteries hard. 

3. Epilepsy. (1) "Haut mal:" aura, convulsions; (a) tonic, respiratory 
muscles affected, face livid, stupor afterward ; (6) clonic, tongue bitten, 
stupor follows. (2) " Petit mal pallor sudden, no convulsions. 

4. Infantile convulsions. Usually reflex from indigestion j may be 
the onset of a specific fever, or due to high temperature. 

5. Puerperal convulsions. Headache, amaurosis, oedema, suppressed 
urine, albuminous ; clonic convulsions, tongue bitten, complete coma. 
(See Uraemia.) 

6. Urcemia. Unilateral or bilateral clonic convulsions. (See Renal 
Disease.) 

7. Alcoholism, opium, and sunstroke. 

8. Organic brain diseases (syphilis, tumor, softening, etc). 

II. Fits with partial or no loss of consciousness. Faintness, angina 
pectoris, hystero-epilepsy, focal or Jacksonian epilepsy, hysteria, cerebral 
embolism, thrombosis or hemorrhage, spasms of various kinds. 

III. Fits with vertiginous movement. The forms of vertigo are gastric, 
aural and labyrinthine (Meniere's, also paroxysmal), ocular, cerebellar, 
congestive of the brain (reflex), epileptic. 

IV. Collapse. This is likewise a condition that may be present with 
the immediate onset of the disease and be noted by the observer on 
the occasion of his first visit. 

The symptoms are those of prostration, with partial loss of conscious- 
ness, or the mind is perfectly clear. The face is pale, pinched, and 
bathed with perspiration (see Hippocratic Facies). The skin is cool 
and clammy. The hands are cold. The skin is wrinkled. The eyes 
are sunken and encircled by dark rings. The voice is weak or sup- 
pressed. The pulse is rapid and thready, or may be absent at the 
wrists. The heart sounds are indistinct. The temperature falls. The 
respiration may be hurried, or shallow, sighing and gasping. The urine 
is scanty or may be absent. Collapse is due to hemorrhage, exter- 
nal or internal ; to perforation of abdominal viscera, to peritonitis, to 
excessive watery discharge, as in cholera or serous purging. It may be 
due to pernicious malarial fever. Coma attends this form. 



THE DATA OBTAINED BY OBSERVATION. 



117 



V. Shock is a condition in which the vital powers are blunted or 
stunned, with or without mental terror or anxiety. In injury, surgical 
operation, hemorrhage, severe pain, undue mental and emotional strain, 
it is likely to be seen. Its presence points to a grave antecedent 
condition, near or remote. The symptoms are those of collapse. 

B. Local Examination of the Exterior. 

The appearance of the face and its expression are observed. The shape 
and size of the head and the mode of carriage are noted. Abnormalities 
must be taken note of, and in addition, local areas about the face, as 
the eye, nose, and ear, particularly inspected. Passing downward from 
the head, the neck should be examined, and from thence a local 
examination of the extremities, independently of the skin, made. Fol- 
lowing this, the bones and joints and the muscles should be studied in 
regular order. 

The Face and the Facial Expression. (See Nose and Mouth in 
respective chapters on special diagnosis.) The face is a mirror in which 
is reflected all degrees of ill health, from that which amounts only to 
temporary indisposition and depression up to the gravest cachexia. The 
face reflects also the degree of intelligence of the patient and his mental 
condition at the time, as well as his emotions, and in a large measure 
his character. The face is usually a pretty good index of the temper 
of the individual ; benevolence, amiability, and purity are written as 
plainly on some faces as auger, lust, dishonesty on others. 

All varieties of mental aberration are reflected in the face ; the sus- 
picious, at times revengeful, look of the delusional monomaniac ; the 
wild look and excited manner of the maniac ; the plaintive, depressed, 
injured look of melancholia; the vacant, listless, peaceable, animal-like 
look of dementia — a look which changes for animation only at the sight 
of food or some coveted luxury. All these expressions come to be 
recognized very readily by those who see much of the insane. 

The face frequently affords us valuable information concerning the 
health, habits, and temperament of the individual. Everyone is familiar 
with the bright eye and animated countenance of a friend which lead us 
to say, " You are looking very well to-day," and with that slight pallor, 
diminished clearness of the conjunctiva, with perhaps a dark circle 
under each eye, which leads us to infer that he is depressed or has passed 
a sleepless night. The face also gives unmistakable evidences of alcohol 
by its bloated appearance, injected or glassy eye, dull expression, and 
nervous manner when addressed suddenly. 

Full-blooded persons, disposed to endarterial changes, frequently as 
the result of gout, often have, at a little distance, the ruddy appearance 
of blooming health. Closer inspection, however, shows that the ruddy 
color is due to a dilated or congested condition of the minute blood- 
vessels. This condition, when associated with high tension in the arteries 
and accentuation of the aortic second sound, is highly suggestive of 
chronic nephritis. (For color, see Skin.) 

Moreover, the face tells of the presence or absence of pain, and, to a 



118 



GENERAL DIAGNOSIS. 



certain extent, of its character. Everyone has witnessed the sudden 
contraction of the brow and eyelids, and the involuntary sucking in of 
the breath when someone has bitten upon a tender tooth. Other faces 
bear the imprint of long-continued, more or less constant suffering. 
According to Eustace Smith, pain in the head in children is indicated 
by contraction of the brows; pain in the chest, by sharpness of the 
nostrils ; and in the belly, by a drawing of the upper lip. 

It will be seen that the expression, the color, and the outline of the 
face are valuable indications of disease. 

The master mind in clinical medicine, the late Austin Flint, Sr., 
tersely described the various appearances of the face in disease, with 
their clinical significance, as follows : 

The Facies of Renal Disease. In some cases of acute albumin- 
uria, and of chronic parenchymatous nephritis — the large white kidney 
of Bright — puffmess of the face from oedema, with notable pallor, ren- 
ders the aspectic highly diagnostic. 

The Malarial Facies. Pallor of the face, sallowness, and slight 
puffiness, if renal disease be excluded, point to malarial disease. 

The Facies of Carcinoma. Notable anaemia, a waxy or straw- 
colored complexion, and more or less emaciation, in combination, render 
the aspect marked in some cases of malignant disease. In a patient 
over forty years of age this aspect has considerable diagnostic import, 
although it is by no means always present when malignant disease exists. 

The Typhoid Facies. In the middle and later periods of typhoid 
fever the countenance is often dull, besotted, expressionless. This facies 
may be present in the typhoid state, which is incident to diseases other 
than typhoid fever, e. g. y pneumonia. Coexisting with a dusky hue 
of the skin and congestive redness of the conjunctiva, it distinguishes 
typhus, as contrasted with typhoid fever. 

The Facies of Acute Peritonitis. The upper lip raised so as to 
expose the front teeth, gives an aspect which characterizes, in a certain 
proportion of cases, acute peritonitis. It is often wanting, but when 
present it is strongly diagnostic. 

The Facies of Acute Pneumonia and Hectic Fever. Circum- 
scribed redness of one or both of the cheeks, with abruptly denned 
borders, is diagnostic of acute pneumonia. If it be observed in a case 
of chronic pulmonary disease, it denotes the so-called hectic fever, and 
is a sign of phthisis. 

The Facies of Exophthalmic Goitre. Projection of the eye- 
balls, giving to the face a remarkably staring and sometimes ferocious 
expression, conjoined with enlargement of the thyroid body and fre- 
quency of the pulse, is distinctive of the affection known as exophthal- 
mic goitre — Graves' disease and Basedow's disease. 

The Choleraic Facies. In the collapsed stage of cholera the face 
is contracted, sometimes wrinkled ; the cheeks are hollow, the eyes 
sunken, the skin is livid, and the expression denotes indifference. This 
combination of traits is quite distinctive. They are, however, to a cer- 
tain extent combined in the state of collapse which occurs in some 
cases of pernicious intermittent fever, and in other pathological connec- 
tions. 



THE DATA OBTAINED BY OBSERVATION. 



119 



The Hippocratic Facies. This facies denotes the moribund state. 
The skin is pale, with a leaden or livid hue ; the eyes are sunken, the 
eyelids separated, and the cornea loses its transparency ; the nose is 
pinched, and the eyes are contracted ; the temples are hollow, and the 
lower jaw drops. Hippocrates described this facies in graphic terms, 
and the name Hippocratic has ever since been used to designate it. 

The Face in Children. Inspection is even more important in 
the case of children than in adults. The pale, pinched, weazened face 
of some babies who have snuffles, ulcers at the corners of the mouth, 
and look prematurely aged, is characteristic of inherited syphilis. In 
rickets the head is unusually large with flattened vertex, projecting 
forehead, and open fontanelle. In hydrocephalus the head becomes 
very much enlarged, the eyes prominent, the bones of the face remain- 
ing small, the expression vacant (see p. 122). In measles the red, 
swollen face, the reddened, weeping eyes, and running nose make a very 
striking picture. An irritating, excoriating discharge from the nose in 
a child may indicate the existence of a nasal diphtheria. 

The Face in Nervous Disease. The face also often tells of the 
existence of some organic nervous disorders. 

In peripheral facial palsy the paralyzed side of the face has a 
staring, vacant expression, owing to the fact that the eyelids are motion- 
less. The angle of the mouth on the affected side is depressed. The 
whole paralyzed side is devoid of wrinkles, has a smoothed-out, glazed 
appearance ; tears flow over the cheeks, and saliva dribbles from the 
corner of the mouth. The contrast with the normal side is most 
marked when the patient smiles or frowns. 

In glosso-labial palsy there is progressive palsy, with tremulousness 
of tongue and lips ; progessive failure of articulation, and dribbling of 
saliva. Sometimes the patient is able to open the lips, but unable to 
close them without the aid of the hand. 

A slow, hesitating, thick manner of speaking, with a tendency to slur 
the labial and lingual consonants, when associated with irregularity of 
the pupils, slight tremulousness of the lips, and the loss of the fine 
adjustment of other muscular movements, such as writing, is very sug- 
gestive of general paralysis of the insane, especially when the condition 
develops in a middle-aged man. 

Facial hemiatrophy is a peculiar affection, characterized by progressive 
wasting of the bones and soft tissues of one side of the face. The dis- 
ease is rare ; it begins, as a rule, in childhood, and may develop in later 
life. The local change is diffuse, although, in some instances, it starts 
at one spot in the skin and spreads, involving, in succession, the tissues 
underneath. The skin changes in color, and the hair falls. The eye is 
sunken on the affected side on account of wasting of the tissues of the 
orbit. Of the bones that waste, the bone of the upper jaw atrophies to 
a more advanced degree than the others. On account of the wasting of 
the alveolar processes, the teeth become loose and fall out. The wast- 
ing is sharply limited to the middle line. The disorder is easily recog- 
nized. The patient looks as if the face was made up of two halves 
from different persons. It must not be mistaken for the facial asym- 



120 



GENERAL DIAGNOSIS. 



metry that is associated with congenital wry-neck. The contraction of 
the sterno-mastoid muscle from birth distinguishes the affection. 

(For spasm and contraction of the muscles of the face, see Disease of 
Cranial Nerves.) 

Having noted the expression of the face and observed the general and 
local color, the outline of the face, with any change in the shape of the 
head, should be observed. The changes in both, as seen in rickets, 
have been described. The striking changes in acromegalia, myxoedema 
and osteitis deformans have also been described in sections referring to 
these affections. 

Enlargement of the Face. Swelling. Other changes in the 
outline of the face and skull are significant. The face is swollen and 
deformed in erysipelas and smallpox. The specific eruption serves to 
distinguish each one. The puffiness of the eyelids and general swell- 
ing of the face, which arises in the course of Bright's disease, will be 
referred to. (See CEdema.) 

In mumps the swelling is characteristic. It usually begins on one 
side first. The swelling of the parotid gland is observed in front of 
the ear, then it extends below and around it and behind the ramus of 
the jaw. Unless there is much collateral oedema, the outline of the gland 
is preserved. The lymphatics may or may not be swollen. It is tender 
and boggy, not indurated. Viewing the face from the front, the mid- 
lateral aspects are seen to bulge. The ears stand out from the 
head. 

CEdema of the face occurs in trichinosis. It occurs at two periods in 
the course of the disease. It is seen in the eyelids in the beginning of 
the disease, and disappears after a few days. Later in the disease it 
returns, with pain, tension, and restriction of the movement of the eye- 
muscles. The oedema may be due to infection of the muscles by the 
parasite or may be of vasomotor origin. 

Hair. The hair often indicates the state of the nutrition of the indi- 
vidual. Changes in it may be significant of syphilis or other internal 
morbid processes. The abnormal growths and changes in the texture 
due to local parasitic disease will not be referred to. Undue and rapid 
falling out of the hair in patches, known as alopecia, is indicative of 
syphilis and of profound intoxication by the virus of this disease. The 
hair can be pulled out in large masses without difficulty or pain. This 
falling of the hair must not be confounded with the excessive falling 
out which takes place in the convalescence of acute disease, and par- 
ticularly of typhoid fever, nor with that following an attack of gout 
or erysipelas. 

Color of the Hair. Obscure paralysis or anaemia may be ex- 
plained by noting the artificial coloring of the hair. Repeatedly lead 
and other poisonings have arisen from the use of hair dyes. Other 
changes in the color are not specially significant, although early gray 
hair may go hand-in-hand with premature endarteritis. The term 
" canities" is applied to the diminished development of pigment. Pre- 
mature gray color in defined patches occurs in nerve lesions, as paralysis 
of one of the branches of the fifth pair, and is a trophic change. 



THE DATA OBTAINED BY OBSERVATION. 



121 



Local Affections of the Skin of the Face. Comedones are papular 
elevations with a central pit of dark color, due to accumulated dirt. 
Milium, from obliteration of the ducts, consists of small, rounded 
papules of whitish color. They are familiar, but are not of special 
significance. In molluscum the entire sebaceous gland is distended by 
altered secretion. Acne is a papular affection, inflammatory in character, 
appearing at the seat of comedones, and may be indurated or pustular. 
In the latter instance pits are left behind. It is commonly seen in 
gouty subjects, in chronic dyspepsia, or liver disturbance. 

The sebaceous glands of the skin of the face merit but a passing notice. 
Deficiencies or excesses of secretion, or alteration of it, are usually due to 
local causes. Excessive secretion of sebaceous matter, known as sebor- 
rhea, or steatorrhcea, is seen in two forms. First, with oily exudation ; 
second, with drying of the secretion and the formation of crusts. It 
may be more pronounced in strumous subjects. The opposite condition, 
or asteatodes, is seen in wasting diseases, particularly diabetes, and in 
xeroderma and ichthyosis. 

% 

The Cranium. The change in shape that takes place in general 
bone affections has been referred to (see preceding pages for rickets, 
acromegalia, osteitis deformans). The peculiar shape due to deformities 
of congenital origin, or deficiency of the bone plates, are not within the 
province of this work. By palpation the fontanelles are examined, 
the presence of bosses detected, and the loose plates adjacent to the 
sutures ascertained. The term craniotabes is applied usually to the 
occurrence of this condition in early rickets. 

Fontanelles. Prominence or fulness is seen in hydrocephalus and 
other brain affections in which there is increase of internal pressure. 
Depression of the fontanelles occurs in general atrophy, marasmus, and 
in wasting diseases generally. It is present in collapse, and is of prog- 
nostic omen. The fontanelles are not changed in rickets, a point of 
distinction between this affection and hydrocephalus and enlargement 
from other internal causes. The bones of the cranium may be 
thickened ; they may be the seat of periostitis, of necrosis, and caries. 
Necrosis and caries of the frontal bone is almost pathognomonic of 
syphilis. Necrosis of the jaw bone belongs to phosphorus poisoning. 
The mastoid and petrous portions of the temporal bone should be ex- 
amined in many affections. The symptoms that should call our atten- 
tion to these bones are pain and tenderness over the mastoid, rigors and 
fever, with thrombosis of the cerebral sinuses, characterized by pain in 
the head, convulsions, and strabismus. Examination in the region 
should extend to the occipito-atlantal articulation. Disease of this 
articulation, and particularly tubercular disease, causes stiffness of the 
neck, or falling forward of the head. On account of the stiffness, 
associated difficulty of deglutition and pain, the writer has seen it 
mistaken for retro-pharyngeal abscess. 

The expression and contour of the face is of much significance in 
cerebral disorders. 

Affections which cause an increase in intra-cranial pressure cause, 
also, striking external features, as in hydrocephalus. 



122 



GENERAL DIAGNOSIS. 



Hydrocephalus. The external enlargement of the skull is very 
conspicuous, and the undue proportion of the cranium to the face is 
striking. The cranium is rounded or globular in shape, and the 
fontanelles are seen to be very large, tense, and bulging, and the 
sutures widely separated. The disproportion in size of the face and 
head is increased by the projection of the front portion of the skull. 
The axis of the eyes is directed downward, and they are partly covered 
by the eyelids, because of the oblique direction of the orbital plates. 
The head is supported with difficulty ; the eyeballs roll from side to 
side. There is frequently strabismus. The skin is stretched tightly 
over the cranium, and the hair is scanty. (See Fig. 10.) 



Fig. 10. 




Congenital hydrocephalus. Female, aged seventeen. (The thinness 
of the hair could not he represented.) 

The enlargement of the head must not be confounded with rickets 
(see under Skeleton) or enlargement and thickening of the bones. In the 
former the head is square in shape, not globular, and the fontanelles, 
though large, do not bulge. Other signs of rickets aid in the distinction. 
Gowers states that thickening of the cranial bones may simulate hydro- 
cephalus at almost any age. He thinks it doubtful whether the nature of 
the latter rare cases can be ascertained during life. The thickening 
that attends osteitis deformans and acromegalia have been already 
described. 



THE DATA OBTAINED BY OBSERVATION. 



123 



The Lips. The color of the lips is pale in anaemia, and livid in 
cyanosis from chronic lung or heart disease with feeble circulation. Vesi- 
cles (herpes) are apt to appear upon them in common colds, in certain 
febrile diseases, particularly pneumonia, and with many women during or 
immediately following menstruation. A child with hereditary syphilis 
may show ugly fissures, or the scars which result from them, at the 
angles of the mouth. In facial palsy the angle of the mouth on the 
paralyzed side is depressed and free from wrinkles. In glosso-labial 
laryngeal palsy the lips tremble, twitch, and may have to be closed with 
the fingers after they have been opened. In general paralysis of the 
insane the lips tremble, and speech is " thick," hesitating, and uncertain, 
with a tendency to elide syllables and slur the labial consonants. 

The Eye. Appearance of the eyelids in oedema has been described. 
The dropsy may accumulate during the night in little bags under the 
lower eyelid. It is seen in the morning on rising, and disappears by 
night. (See (Edema.) It must not be confused with the morning puffi- 
ness that seems to be natural to some individuals, or the swollen face 
that succeeds a debauch. We sometimes see a peculiar change of the 
skin of the eyelid due to xanthelasma. In addition to its occurrence in 
this situation, the palms of the hands, the flexures of the fingers, 
and the inside of the mouth are affected (see under Tongue) t On the 
eyelids are seen patches slightly elevated, of a yellowish color, irregular 
in shape. They are slightly sensitive to the touch but not indurated. 
The cuticle is healthy. They are due to oil deposited in the neighbor- 
hood of the hair follicles, in the substance of the cutis. Sometimes they 
are arranged in the form of tubercles as large as a pea. 

Drooping of the eyelids may occur from paralysis of the third nerve. 
It is known as ptosis. (For this and affections of the oculo-motor 
and optic nerve, see under The Eye — Nervous Diseases.) 

The Open Eye. This is known as lagophihalmos. It is due to 
paralysis of the orbicularis palpebrarum. It is present in more or less 
degree in exophthalmic goitre. 

Exophthalmos. The eyeball protrudes more or less from the socket 
in tumors of the nose or orbit. 

In exophthalmic goitre both eyeballs protrude, and with the change in 
the appearance of the neck give to the patient the so-called ferocious 
appearance. The protrusion of the eyeballs is readily recognized 
because it is bilateral. The so-called Yon Graefe's sign further 
aids in the diagnosis. This sign consists in lagging of the upper lid in 
movements of the eyeball. When the patient looks down the lid does 
not readily follow the movements of the ball downward. 

Stellwag's sign is the third sign of significance in exophthalmic goitre. 
There is undue exposure of the cornea. One or both signs may be 
absent in cases of exophthalmic goitre. 

Sunken Eyes. Sunken eyes are due to atrophy of the fat of the 
socket in phthisis or wasting diseases. It is most pronounced in the 
sudden atrophy that occurs in cholera from loss of water. It is also 
seen in peritonitis and collapse from other causes. 

Examination of the Conjunctive. The conjunctiva? may be 



124 



GENERAL DIAGNOSIS. 



the seat of inflammation from local causes. Its occurrence in the course 
of general or internal disease concerns as. It is often seen in disease 
of the brain or the meninges, and sometimes it occurs early in the course 
of the affection. In tuberculous meningitis purulent conjunctivitis is of 
common occurrence. Usually one side is more highly inflamed than 
the other. Along with other symptoms of involvement of the cranial 
nerves, the conjunctivitis is of diagnostic significance. In measles con- 
junctivitis is seen early. In typhus fever it is a constant sign and serves 
to distinguish the affection from typhoid. In yellow fever the mild 
conjunctivitis causes the watery ferret-eye. The conjunctiva is used to 
determine the degree of sensitiveness of a patient who is more or less 
comatose. 

The Color. The normal color of the ocular conjunctiva is clear 
white. In jaundice it is yellow. It is yellow in small areas from fat 
in the obese and aged. The fat is in cone-shaped areas. The pearly 
sclerotic of chlorosis, the dead-white color of anaemia, as in Bright's 
disease and phthisis, are striking in these affections. The palpebral and 
outer conjunctiva is the seat of hemorrhage in epilepsy, whooping- 
cough, asthma, and of hemorrhagic infarcts in ulcerative endocarditis. 
(See Disease of Cranial Nerves for movements of eyeball, the iris, ap- 
pearance of the retina, etc.) 

The Cornea. Ulceration of the cornea in addition to other causes 
occurs as a trophic lesion due to paralysis of the first branch of the 
trifacial nerve. It may occur in paralysis of the eyelid from exposure. 
Opacities result from such ulceration or may be due to syphilis. In 
congenital syphilis the remains of keratitis are frequently seen. The 
" arcus senilis" is observed in the circumference of the cornea at its 
junction with the sclerotic. It is a distinct arc but is not always a 
complete circle. The cornea is hazy and may have fat granules. The 
eyelids must often be lifted to recognize it. Its edges are ill-defined* 
In contradistinction to this, Fothergill calls attention to the false 
" arcus senilis " — a well-defined ring which encircles the pupil ; but the 
cornea is always clear and the person in good health, although aged. 
The true arcus senilis is seen in the gouty, in arterial sclerosis, and in 
nephritis. It is an early indication of degeneration of the arteries. 

The Ear. In an exhaustive general examination, either with the 
object of determining the body health for life insurance, or in order to 
determine the cause of ill health, the external ear should always be ex- 
amined. This should be particularly the case in inflammations of the 
meninges or other disease of the brain. In otherwise unexplainable 
cases of pysernia or of pysemic symptoms (alternating chills and fever), 
the presence of discharge from the ear should be inquired for, as very 
frequently middle-ear disease results in inflammation of the mastoid, 
and from thence the sinuses and membranes of the brain adjacent become 
inflamed, or the suppuration may be the primary focus from which 
general infection takes place. It may not be possible in all cases to 
observe a discharge. It may have diminished or disappeared on account 
of the fever. Tenderness and cedema over the mastoid, and direct 
inspection of the ear drum, by which a perforation, or other charac- 



THE DATA OBTAINED BY OBSERVATION. 



125 



teristic changes may be seen, point to the occurrence of suppuration 
in this situation. It must not be forgotten that in fractures of the 
skull a bloody discharge from the ear may take place. In cases of 
coma from injury, or if of obscure origin, the ears must also be ex- 
amined. 

The External Ear. From the exterior of the ear we derive but little 
data of diagnostic significance. It is true the thin ear may show the 
anaemic or chlorotic hue more strikingly than other portions of the 
body ; or the opposite condition may be more vividly shown. Hcema- 
toma auris is seen in general paralysis of the insane and other forms of 
insanity. It is a tropho-neurosis. The ear is thickened and deformed on 
account of effusion of blood between the cartilages and the peri- 
chondrium. It is discolored and simulates the subcutaneous effusion due 
to injury. Apart from color changes tophi are observed on the external 
ears of patients with a gouty diathesis. They are small, hard, gritty 
accretions seen on the external ears along the margin, or in the depres- 
sions. They consist of urate of soda. 

The function of hearing must be inquired into and its acuteness 
tested. This may be done with the voice, with the watch, and with the 
tuning-fork. The voice may be heard well in some cases when the tick- 
ing of a watch can be perceived with great difficulty. The tuning-fork 
is used to determine whether the deafness is due to (1) obstruction or (2) 
disease of the internal ear. If it is due to obstruction the fork is heard 
better on contact with the skull than when the sound is heard in the 
natural way through the ear. Deafness of this character is always due 
to disease of the external meatus, the tympanic membrane and middle 
ear, or the Eustachian tube. 

Deafness due to disease of the internal ear may be clue to affections of 
the labyrinth, as caries and necrosis, or diseases of the auditory nerve. 
The tuning-fork is not heard on contact with the skull. The auditory 
nerve may be diseased in its course, or the auditory centre may be 
affected. Tumors, meningitis, hemorrhage, and infectious diseases may 
involve the auditory nerve, while the auditory centre is affected by tumor, 
meningitis, abscess, or hemorrhage. (See under Cerebral Localization.) 
It must not be forgotten that certain drugs, as quinine and the salicylates, 
may cause deafness. 

The Neck. Shape and size of the structures. The position of the 
trachea and larynx, the seat and size of the thyroid gland, and the 
appearance of the vessels of the neck, should be observed. The trachea 
and larynx occupy the median line in health, but may be deflected to 
the right or left. The deflection is more readily noticed at the lower 
part of the neck, and can be ascertained by fixing the relationship to 
the adjacent muscles. The change in position is due to disease within 
the thorax. An aneurism or mediastinal tumor may cause this altera- 
tion. In cases of chronic fibroid phthisis the trachea is pulled to the 
side of the affected lung. Movements of the larynx and trachea are 
observed, and when in excess and associated with dyspncea the source 
of the dyspncea is in the larynx. When, on the other hand, they are 
not moved, or indeed remain fixed notwithstanding violent efforts at 



126 



GENERAL DIAGNOSIS. 



respiration, the dyspnoea is due to disease in the mediastinum. This 
form of dyspnoea occurs from enlargement of the mediastinal glands 
or from aneurism pressing upon a bronchus. Observation of the condi- 
tion of the trachea and larynx is made by inspection and by palpation. 
Both are employed in diseases of the larynx (see Larynx) and the latter 
in order to detect the physical sign due to tugging or drawing on the 
trachea by disease within the thorax. Tracheal tugging may be seen, 
but is usually determined by palpation. It is particularly characteristic 
of aneurism of the descending portion of the aorta. The aneurismal 
sac presses upon the bronchus, and on account of its relationship with 
each pulsation of the vessel, the tugging or pulling downward of the 
trachea can be felt. (See Diseases of the Vessels.) 

Thyroid Gland. It may be enlarged or diminished in size. The 
atrophy of the gland is shown by absence of fulness, which should 
otherwise be present in the neck of the individuals of the age of the 
patient under examination. (See Myxoedema and Acromegalia.) 

Enlargement of the Thyroid can be detected without much diffi- 
culty. It may be limited to one lobe, or both lobes may be affected. It 
may vary in size from a small localized swelling to large masses "which 
fill the median and lateral sides of the neck, pressing upon the trachea. 
On palpation the swelling may be soft or hard. In the fibrous forms 
the swelling is not very large and is very much indurated. In the 
cystic forms of the thyroid enlargement fluctuation may often be 
detected ; it may be localized to a small area of the lobe or may be 
detected over the entire affected lobe. On palpation in some cases a 
purring or thrill is transmitted to the fingers. The thrill is synchronous 
with the heart's action, due to great vascularity of the parts. Auscul- 
tation over the gland when a thrill is present reveals a murmur systolic 
in time and low in pitch. 

Causes. Enlargement of the thyroid gland may be due to simple 
hypertrophy, to fibro-cystic enlargement, or to enlargement in which the 
vascularity is more prominent, as in exophthalmic goitre. In simple 
hypertrophy the enlargement is often intermittent, increasing in size at 
each menstrual period, or coming on in pregnancy, to disappear after 
labor. It may then disappear entirely, or again return at the menopause. 
The fibro-cystic enlargement which occurs in countries in endemic form 
persists. The enlargement Avhich is chiefly due to dilatation of the blood- 
vessels is usually seen in exophthalmic goitre, and can easily be recog- 
nized by the association of the remarkable signs of this affection. (See 
Exophthalmic Goitre.) 

Enlargement of the thyroid gland must be distinguished from enlarge- 
ment due to other causes, as cancer, sarcoma, or adenoma. It must also 
be distinguised from other tumors in this region. It particularly must 
not be confounded with enlargement on the right side due to an innomi- 
nate aneurism. (See Aneurism). The distinction can usually be made 
without difficulty. (For lymphatic glands of neck, see The Glands). 

The Vessels of the Neck. The large veins of the neck form 
an accurate clue to the state of the circulation within the veins. Their 
close proximity to the heart in the direct line which the blood takes to 



THE DATA OBTAINED BY OBSERVATION. 



127 



reach the heart causes other changes which indicate the state of the 
circulation in that organ. (For a description of these changes see 
Arteries and Veins.) 

The observation of the thorax and abdomen will be considered under 
sections devoted to affections of the respective regions. 

The Extremities. The Hands. Color. Observations of the 
color of the hands is of service in estimating the general hue and color 
of the individual, as changes are noted earlier in the distant points of 
the circulation. (See the Skin — color.) Shape. Changes in the shape 



Fig. 11. 




Pseudo-muscular atrophy. Claw-hand. (Gray.) 



are pronounced in many affections. The spade-like hands of myxoedema 
have been referred to, the peculiar shape of the hands in acromegalia 
and pulmonary osteo-arthropathy described, and the appearance in 
rheumatoid arthritis also discussed. In 'progressive muscular atrophy 
(chronic anterior myelitis) the shape of the hands is peculiar. The 
French name main-en-griffe is applied to it. Both hands are affected, 
although it may have begun in one before the other. From wasting 
of the muscles voluntary power is lost. The thenar muscles and the 
interossei are the first to suffer. The thenar eminence becomes flat- 
tened, the base of the first metacarpal bone more prominent. The 
atrophy of the abductor indicis is so conspicuous that the normal 
prominence near the thumb w r hen it is adducted gives place to a hollow 
beside the metacarpal bone. There are marked depressions between 
the metacarpal bones and the flexor tendons of the hands. The 
phalanges assume positions dependent upon the degree of atrophy of 
the flexors or the extensors of the forearm. The extensors on the 
ulnar side usually atrophy the most, and the extensors of the phalanges 
of the thumb more than that of its metacarpal bone. A peculiar claw- 
hand is produced on account of these contractions. 

Rheumatoid Arthritis. The shape of the hand somewhat resem- 
bles that of muscular atrophy. While there is considerable atrophy of 



128 



GENERAL DIAGNOSIS. 



the muscles there is also change in the ends of the bones and joints. 
The ends of the bones are enlarged and the cartilages undergo atrophy. 
The joints of the phalanges may be swollen and the tissues infiltrated 
prior to the destruction of the cartilage. This may have been present 
for a long time, increasing in amount at different periods with pain and 
tenderness. The joints gradually become more immobile, the infiltration 
disappears, and the enlarged ends of the bones become more prominent. 
More or less ankylosis develops, and on motion crepitus and grating is 
felt on account of the eroded cartilage. Osteophytes may form in the 



Fig. 12. 




Rheumatoid arthritis. The phalangeal joints are swollen; many are ankylosed. The wrist is 
stiff. The muscles are atrophied ; the forearm muscles much wasted. 



tendons, so that the joint becomes more completely locked. Atrophy 
of muscles supervenes on account of the disease of the joint. Some- 
times the wasting is very extreme and gives the hand the appearance 
that is seen in pseudo-muscular atrophy. The general symptoms 
that attend each affection serve to distinguish them. Eheumatoid 
arthritis is easy of recognition when the other joints are involved in 
the process. 

Contractions of the hand may often be observed from other causes 
than the ones just mentioned. Temporary contractures occur in tetany, 
in temporary hemiplegia or monoplegia, and in paralysis of the exten- 
sors. So-called wrist-drop is seen in peripheral neuritis, particularly in 
the form due to lead. The hand hangs from the wrist on account of 
paralysis of the extensor muscles of the forearm. Both hands may 
drop, although dropping of one is seen from a few days to a few 
weeks before that of the other. It develops gradually. At first the 
patient cannot extend the fingers at the metacarpophalangeal joints. 
The thumb also suffers, and the weakness of the extensors is most 



THE DATA OBTAINED BY OBSERVATION. 



129 



marked on the ulnar side. At the beginning, if the first phalanges 
are passively straightened the distal phalanges can be extended by 
the unaffected interossei muscles. The loss of power extends to the 
wrist. The extensors of the wrist do not suffer equally. Those of the 
radial side are affected first. When the paralysis is complete the hand 
drops and cannot be brought to the level of the forearm. It may be 
noted that if the fingers are flexed passively the patient is able to close 
the fist as long as the special extensors of the wrist retain power. If, 
however, the fingers are extended the wrist cannot be extended. The 
muscles affected, therefore, are the common extensor of the fingers, the 



Fig. 13. 




Photograph of a case of lead-paralysis affecting the extensor muscles. (Gray.) 

extensor indicis, the extensor of the phalanges of the thumb, and those 
of the wrist. The flexors of the fingers are unaffected. The continued 
over-flexion of the carpus produces slight displacement backward of the 
carpal bones, and a prominence forms over the carpus and the dorsum 
of the hand, which alarms the patient but is of no consequence. It 
is known as Gubler's tumor. 

The Skin. The skin of the hand need not concern us, save as 
estimated in connection with the skin of the rest of the body. It is 
smooth or rough, dry and harsh, moist and warm, under the same cir- 
cumstances that affect the skin generally. In rheumatoid arthritis it 
has been particularly described as peculiar. Both the dorsal surface 
and the palm are moist and very soft, and the former dotted with 
freckles. 

The swellings of the hand, inflammatory or cedematous, do not differ 
from swellings in other portions of the body, whether the joints are 
affected or the subcutaneous connective tissue, except in the cases pre- 
viously mentioned. (See Skin.) 

9 



130 



GENERAL DIAGNOSIS. 



Fingers. In gout and rheumatism the fingers present changes. 
The swelling of the joints in each condition cannot well be distinguished. 
In gout, tophi are likely to be present in the joints or along the tendons, 
on account of great accumulation of urate of soda. They are more prom- 
inent on the dorsal surface of the joints, and sometimes break through 
the skin, so that the " chalk-like " concretion exudes. It was said by 
Sir Thomas Watson that a gouty subject under his care utilized his joints 
in keeping tally while playing cards. 

Heberden's Nodosities. The term " end-joint arthritis" is also 
applied to these nodes. The nodules develop gradually at the sides of 
the distal phalanges. The subjects may be in good health, or may 
have had attacks of gout, or have suffered from acid dyspepsia. At 
first the joints may be a little swollen and tender. The swelling and 
tenderness may occur in paroxysms, and with each paroxysm the size 
may be larger than at the preceding paroxysm. The tubercles are seen 
at the side of the dorsal surface of the second phalanx, the corre- 
sponding cartilage becomes soft, the ends of the bone may be eburnated. 
A moderate ankylosis takes place. They are often considered of good 
prognostic omen ; it is even said they are a sign of longevity. It is cer- 
tain that the large joints are not involved when these nodosities are present. 

In acromegalia and pulmonary osteo-arthropathy the state of the 
fingers has been described. Heberden's nodes and Hay garth's nodosi- 
ties have also been noted. The tips of the fingers are bulbous, or club- 
shaped, in cases of phthisis and in other forms of chronic lung disease 
and in chronic heart disease. It is most common, however, in bronchi- 
ectasis and phthisis. The clubbing is associated with changes in the 
nails (see infra). In addition to the nodosities above mentioned, extra- 
articular tophi which develop in the course of gout must be referred to. 

Deviations in the Position and Shape of the Fingers. 
Changes in the shape of the fingers occur as described in connection 
with the changes in the shape of the hands. The eversion in rheu- 
matoid arthritis is characteristic of that affection, but deviations due 
to abnormal flexion or extension produce the most marked changes. 
Flexion of the first phalanx of the little finger is due to contraction 
of the palmar fascia, or to paralysis of the common extensor on account 
of disease of the musculo-spiral nerve. 

Contraction of the fascia of the hand, on account of which the little 
and ring fingers are flexed in more or less degree, is frequently seen, and 
may be an indication of gouty diathesis. It is certain that these con- 
tractions are seen in several members or generations of a family in 
which gout is prevalent. It is called Dupuytren's contraction. 

Abnormal extension is usually very marked. When the middle pha- 
langeal joint is affected the hyper-extension is due to disease of the median 
nerve, on account of which there is paralysis of the flexor sublimis ; 
there is hyper-extension of the distal joints, with paralysis of the flexor 
profundus muscles from disease of the median and ulnar nerves. In main- 
en- griffe, previously described, there is extension of the proximal phalanx 
with extreme flexion at the same time of the two distal phalanges, due 
to contraction of the long extensor and of the flexors. Contractions 
due to chorea or to central lesions, as post-hemiplegic contractions, will 



THE DATA OBTAINED BY OBSERVATION. 



131 



be considered under special diagnosis. It is thus seen that the peculiar 
combined extension and flexion, causing abnormal shape of hands and 
fingers, is due either to (1) local joint inflammation (subluxations) ; (2) 
local neuritis and paralysis; (3) progressive (spinal) muscular atrophy; 
(4) idiopathic muscular atrophy, rarely. 

Athetosis is a peculiar spasmodic affection of the fingers and toes, 
often hereditary, and nearly always associated with imbecility or some 
intra-cranial lesion. It may be unilateral or bilateral. There is contrac- 
tion or paralysis of the affected limb. The muscles may be atrophied 



Fig. 14. 




Case of athetosis. (Gray.) 



or hypertrophied. The characteristic feature is the slow, wavy, and 
gradual movements, which are continuous. The fingers constantly 
tend to pronate, but the toes do not separate. 

Tropho-neurosis of Fingers. Changes in the appearance of the 
extremities and nutritive changes are seen, due to diseases of nerves 
which control nutrition. 

The Circulation. Raynaud's Disease. Local asphyxia. In 
certain vasomotor affections the hand or fingers become pale, intensely 
cold, are the seat of numbness, and are without sensation. The term 
" dead jingers" graphically describes the appearance. The pallor 
usually comes on suddenly, and continues for a short or long period of 
time. In some instauces it occurs in distinct paroxysms. The disap- 
pearance of the pallor is marked by a gradual return of warmth to the 
part and change in color to a livid red, dark blue, or even blackish 
hue. In some cases the livid ity becomes so intense that gangrene in 
small superficial spots, or involving the whole finger, ensues. Pain may 
or may not be present, but is not increased when the hand hangs down. 



132 



GENERAL DIAGNOSIS. 



The tip of the nose and the lobe of the ear may be affected. The sen- 
sation to touch is markedly lessened. Raynaud's disease, for this is the 
affection under consideration, occurs usually in ill-nourished subjects or 
after an acute disease, as typhoid fever. 

Erythromelalgia. Local changes in color are due to peripheral 
neuritis or neuritis of the terminal endings of the nerves. 

Erythronielalgia is characterized by redness of the surface with in- 
creased temperature ; it is usually seen in the extremities and limited to 
the distribution of nerve areas. It is worse in summer, increased by 
heat, and aggravated when the extremity is dependent or pressed upon. 
The redness is attended by burning, by most extreme local discomfort, 
in which all sorts of sensations are described. Tearing of the finger- 
nails, pulling or pricking of the skin, twistings of thousands of needles, 
and other painful sensations have been used to describe the suffering. 
I know of no peripheral pain which is the source of greater agony. 

Glossy Skin is seen after nerve injuries and neuritis, and in cen- 
tral affections in which the trophic nerves are involved. The skin is 
shiny, smooth, drawn very tightly over the surface, and sometimes 
atrophied. Red and pale mottling may be seen. The surface is free 
from hair. Burning pain precedes and accompanies the change. (See 
Nails.) In addition to the gangrene previously noted, other pronounced 
trophic changes are seen in the extremities. Perforating ulcer of the 
foot is an example of such change ; it is usually seen in affections of the 
general nervous system, such as tabes dorsalis. 

The Nails. The Shape. The appearance of the nails gives infor- 
mation as to the duration of some diseases or of convalescence, and to 
the local interference with the nutrition of the parts. Thus, curving of 
the nails, with the club shape of the finger-ends, occurs only in chronic 
diseases, as in cases of phthisis or emphysema, or in chronic cardiac dis- 
ease and aneurism. In the latter it is sometimes found on one hand 
only. It is sometimes seen in other chronic wasting diseases. The nails 
may curve transversely or longitudinally. When transversely the appear- 
ance is like that of a filbert, and when longitudinally they are said to be in- 
curvated. This change in shape may occur without clubbing of the fingers. 
The shape is altered in acromegalia and pulmonary osteo-arthropathy. 

Color. White marks on the surface are usually seen after an ill- 
ness, and may indicate the length of time since the illness occurred. 
The marks develop at the root of the nail, and their position denotes 
the time that has elapsed since convalescence set in. If they are 
seen half-way up the nails, convalescence is probably of three months' 
duration. We get a good idea of the condition of the blood in the 
capillaries from the appearance of the tissue under the nails. If there is 
anaemia, pressure on the finger-tips will drive the blood from the capil- 
laries. Stephen Mackenzie's rule, that if such pressure completely 
empties the vessels so that they are pale it indicates that the globular 
richness of the blood is reduced one- half, is a fair and quick test to 
indicate the degree of anaemia. The purplish and bluish-black dis- 
coloration of cyanosis previously referred to is first seen under the 
nails. Sometimes the capillaries pulsate, and this pulsation is more 



THE DATA OBTAINED BY OBSERVATION. 



133 



visible in the nails than in other parts of the body, except the retina. 
It occurs in the course of aortic regurgitation. 

Nutritive Changes. The nails undergo chronic inflammation 
with destruction in various skin affections, and the matrix is the seat of 
acute inflammation in onychia. Onychia may be simple or syphilitic in 
its nature. Its presence may explain the course of obscure nervous 
phenomena. It may be limited to a simple inflammation, or with sub- 
sequent loss of the nail and further ulceration going on to necrosis. 

Deformity of the nails (toe) occurs in acute and chronic myelitis. 
In locomotor ataxia the nails fall out. In neuritis the trophic change 
is marked ; the growth is arrested and the nail becomes dark and 
brittle and curved in its long axis, while lateral arching takes place. 
The cutis underneath thickens and the skin at the base retracts. The 
fingers may be clubbed. When growth is resumed a roughened dis- 
tinct line of demarcation is seen. In some cases they become dry, 
scaly, and cracked, or atrophy entirely. In hemiplegia from cerebral 
apoplexy the growth is arrested on the paralyzed side. This is tested 
by staining the nails of the two hands at the same level with nitric acid ; 
the relative position of the stain upon corresponding nails of the two 
hands will show whether there has been growth or not. The return of 
functional power is indicated by renewed growth. 

The Feet. The feet and ankles are examined to determine the color, 
the temperature, the occurrence of swelling (oedema), and fixation. Pain 
in the feet has been referred to ; oedema has also been discussed. The 
changes in color are allied to the same in the hand if bilateral. 

Cold Hands and Feet. Changes in the temperature of the ex- 
tremities are frequently complained of by patients, and on examination 
we find it actually reduced. It is a common and often a serious com- 
plaint. It is natural to expect a peripheral coldness when the central 
organ of circulation is weakened. In the final hours preceding death 
coldness takes place. But in organic disease of the heart, with impair- 
ment of the circulation, we also see it. It is a common vasomotor 
condition in states of nervousness independent of hysteria. A visit to 
a physician, excitement from any cause, is likely to be attended by 
coldness of the hands and feet. Under these circumstances the extrem- 
ities are bathed in perspiration of a cold and clammy character. In 
endarteritic changes occurring in the aged, cold hands and feet fre- 
quently occur. They are an index of the state of the peripheral circu- 
lation, and may explain the cause of many of the symptoms which so 
frequently accompany it. 

In gout and rheumatism, and in morbid conditions in which poison 
circulating throughout the body irritates peripheral and vasomotor 
nerves, cold hands and feet are likely to be annoying. Patients with 
forms of indigestion, as well as the above-mentioned states, complain 
of this affection constantly. 

Changes of sensation in the skin of the extremities will not be con- 
sidered in this section. The alterations are so bound up in diseases of 
the nerves that an account of their diagnostic features will be considered 



134 



GENERAL DIAGNOSIS. 



in the chapters devoted to these diseases. It is sufficient to state that 
anaesthesia is seen in local areas and from causes limited to the skin in 
morphoea, in the anaesthetic form of leprosy, and in certain ischemic 
states (urticaria). The loss of tactile sensibility accompanies it. Hyper- 
esthesia and paresthesia occur with various local affections, but are 
without diagnostic significance, except in nervous diseases. 

The Lymphatic G-lands. (See Xeck.) Examination of the condi- 
tion of the lymphatic glands leads to information which may be of 
diagnostic value. They may be enlarged in infectious diseases, notably 
syphilis. The post-cervical glands, the epitrochlear glauds, and lymph- 
atic glands in other portions of the body, point to this condition. In 
the former localities the enlargement is of great diagnostic importance, 
as it is less likely to have been caused by other conditions. The 
enlarged glands that suppurate in local areas do not here concern us. 
Inguinal and axillary enlargement. With or without suppuration, en- 
largement always points to an irritation or lymphatic invasion in the 
area which the affected lymphatic gland drains. When in the groin, 
the feet are affected, and when in the axillae, the hands. Great enlarge- 
ment in either situation causes oedema of the corresponding extremity, 
if the veins are pressed upon. The axillary glands are early affected 
and enlarged in mammary cancer. The breast should always be ex- 
amined in oedema of the arm. 

The supra-clavicular glands. The only local enlargement that is of 
special diagnostic significance is that which is seen above the clavicle 
on the left side. The glands are enlarged and indurated, and may 
cause pressure symptoms. With other symptoms they point to the 
occurrence of carcinoma of the stomach. Indeed there are cases of this 
disease in which the general symptoms of carcinoma alone are present. 
Local symptoms are wanting, and the locality of the cancer cannot be 
made out. The enlarged glands above the clavicle are a pretty sure 
indication that the disease is seated in the stomach. Enlargement in 
this locality is probably due to transmission of the infection along the 
thoracic duct and the associated glands. The cervical and sub-maxillary 
glands The enlargement of the sub-maxillary and cervical glands 
points to affections of the mouth and throat, and disease of the jaw 
and teeth. It is caused particularly by infectious disorders in these 
localities. 

The glands are enlarged in adenitis, tuberculosis, Hodgkbi's disease, 
leucocythcemia, sarcoma, and cancer. The moderate enlargement of syph- 
ilis and local enlargement from irritation in the area of lymph drainage 
has been spoken of. Adenitis is usually local. The gland is tender ; the 
connective tissue around it is affected. There is local heat and pain. At 
first the gland is hard, then softens in the centre, and finally exhibits 
fluctuation. In tuberculosis more than one gland is affected. Usually 
the disease is bilateral (as in the neck). At first the glauds are isolated. 
Later they become matted. The local symptoms are not marked, and 
are very indolent. The course is slow. Thick, cheesy pus is removed, 
which may contain tubercle bacilli. It always causes tuberculosis when 
inoculated in lower animals. Fever and " decline" occur later, but 



THE DATA OBTAINED BY OBSERVATION. 



135 



often not until other structures, as the lungs, are infected. (See Hodg- 
kin's Disease, and Leucocythsemia.) 

Lymphangitis or angioleueitis. The streaked redness over the sur- 
face of the skin, with tenderness along the course of the lymphatics and 
oedema below, characteristic of inflammation of the lymphatic vessels, 
need not be further mentioned. The characteristic appearances that 
are seen in elephantiasis, associated with a change in the urine known as 
chyluria, with or without lymph scrotum, point in an unerring manner 
to the occurrence of the affection due to the filaria sanguinis hominis. 

Muscles. The Nutrition. The nutrition of the muscles is observed 
with the hand of the examiner when the muscles are made to relax 
and contract alternately. (See Vierordt.) Comparison of corresponding 
muscles of the two sides is made. Change is observed more accurately 
by measurement of the limbs at corresponding situations. The muscles 
may atrophy or hypertrophy. Either condition may be local, unilateral, 
or general and bilateral. Atrophy is due to several causes : 1. The 
atrophy of disuse. 2. The atrophy of degeneration. It occurs in 
lesions of the motor path, cortical, medullary or spinal, or in neuritis. 
(See Nervous Diseases.) 3. Myopathic atrophy. 

Atrophy. Atrophy of the muscles from disuse or disease of the 
muscle must be distinguished from atrophy due to disease of the nerves 
(neuritis) and degeneration of motor nerves and ganglia. The former 
is also known as the atrophy of inactivity. The muscles are slightly 
diminished in volume. The atrophy takes place very slowly. It 
supervenes in cases of paralysis. It occurs in joint disease on account 
of which the limb or a portion of it has been kept at rest. It occurs 
also in joint disease from reflex influences. The electrical sensibilities 
of the muscles are qualitative and unchanged. 

General Atrophy. In cachexias in addition to atrophy of the 
tissues the muscles undergo atrophy. Even in nervous diseases the 
atrophy of the muscles due to the disease markedly increases when 
general wasting takes place. 

Myopathic Atrophy. In this form of atrophy the muscle is sub- 
ject to disease. It diminishes in volume, and finally becomes completely 
shrunken. Complete paralysis rarely ensues, but reaction of degenera- 
tion cannot be determined. This form of atrophy occurs iu idiopathic 
or progressive muscular atrophy. 

Idiopathic Muscular Atrophy. In this affection muscular wast- 
ing takes place with or without initial hypertrophy. Three forms are seen : 

1. Atrophy, with Pseudo-Hypertrophy. It usually begins in 
children, and is often of congenital origin, transmitted through the 
mother. It is first noticed just as the child is learning to walk. The 
extensors of the leg, the glutei, the lumbar muscles, the deltoids, and the 
triceps and infraspinati muscles are involved, but the primary change 
takes place in the muscles of the calves. The muscles of the face, neck, 
and forearm are not usually affected in this form ; the muscles of the 
hand are not involved. While hypertrophy progresses in certain mus- 
cles, others waste. The calves may hypertrophy, for instance, while 



136 



GENERAL DIAGNOSIS. 



the extensors of the leg are wasting and become weak. Attitude aud 
gait are characteristic (see page 61). The patient stands erect with the 
legs far apart, the shoulders thrown back, the spine curved, and the 
abdomen prominent. The waddling gait is characteristic, and the 
method of getting up from the floor is pathognomonic. The course of 
the disease is slow, wasting follows the hypertrophy, but the weakness 
is greatest in the primary atrophied groups. Contractures and distor- 
tions of the spine and bones of the leg take place. 

2. Primary Atrophy. This is likewise congenital, and occurs in 
early life. It is divided into different types according to the groups of 
muscles that are affected. The same process occurs as in the former, 
except that pseudo-hypertrophy is not primary. There may be several 
forms in different members of the same family. 

a. The juvenile form of Erb. The upper arm and shoulder and the 
thigh muscles are first involved. Later the muscles of the gluteal 
region and calf may be enlarged and hard. The back muscles are 
gradually affected, and the attitude previously mentioned is taken. The 
reaction of degeneration is not present. In addition, the infantile type 
first described by Duchenne, or the fascio -scapulohumeral type is seen. 
Erb's form begins about puberty. The other forms begin in child- 
hood, but may be delayed. The face is involved; it is expressionless, 
so that in laughing the muscles move slowly ; and the lips cannot 
be employed in whistling, as they are thick and everted. The eyes re- 
main partially open. The muscles of the group waste; later the thighs 
become involved. Erb has given a useful test to determine the strength 
of the shoulder and girdle muscles. When the child is lifted by the 
armpits, if the scapulo-humeral groups are weak the shoulders are 
forced up to the child's ears without resistance. 

Diagnostic Features. The disease is characterized by gradual pro- 
gression of the wasting and weakness in various groups of muscles not 
especially related. We never see wasting of the intrinsic muscles of 
the hand, as in the spinal forms of muscular atrophy, or of the tongue, 
pharynx, larynx, and eye. Electrical irritability is lessened, and reac- 
tion of degeneration is not present. Fibrillary twitching is not seen. 
Sensation is not affected. The reflexes are diminished, and later may 
be lost. The sphincters are not involved ; deformities about joints or 
of the spinal column may occur. A peroneal type of muscular atrophy 
has been described by Charcot. The extensors of the great toe and 
afterward the common extensors and peronei muscles are affected ; club- 
foot results. The muscles of the thigh may become involved later. 
When it occurs in childhood the disease gradually progresses to the 
upper extremities. The muscles of the hand become affected, in which 
it differs from other forms of muscular atrophy. The thenar, hypo- 
thenar, and interossei muscles are symmetrically involved, producing 
the claw-hand. Unlike the other forms of atrophy embraced under 
this heading, disturbances of sensation have been described, and in 
addition pain, fibrillary contractions, and vasomotor changes. The 
reactions of degeneration may be present. It is thought by competent 
observers that it is simply a form of neuritis. 

The diagnosis of idiopathic muscular atrophy is not difficult, if the 



THE DATA OBTAINED BY OBSERVATION. 



137 



above-mentioned facts are borne in mind. The occurrence in family 
groups is important to remember in the diagnosis. In cerebral atrophy 
there is primary loss of power. In chronic anterior poliomyelitis {spinal 
atrophy), atrophy begins in the muscles of the hands first; in both the 
simple and the spastic form there are reactions of degeneration, fibril- 
lary twitching and increase in the reflexes, and in the latter spastic 
contraction of the legs. The myopathies occur early in life and are 
hereditary. 

In neuritis the paralysis is proportionately greater than the atrophy. 
Sensory symptoms are often present. The cause is distinct. There is 
no family history. 

Hypertrophy of the Muscles. Hypertrophy of individual mus- 
cles occurs from overuse, and is seen when one extremity or one portion 
of the trunk is used, and comparatively in excess, in the daily pursuit. 
General hypertrophy of muscles occurs in Thomsen's disease. True 
hypertrophy is recognized by increased volume, great hardness and 
increased vigor of the muscle. 

Pseudo-Hypertrophy (see under Muscular Atrophy) is associated 
with increased volume of muscle, but diminished power. 

Thomsen's Disease. [Myotonia congenita.) This is an hereditary 
disease and may occur in several generations of a family. Tonic cramps 
take place in the muscles when an attempt is made to make voluntary 
movements. The disease begins in childhood, rarely after puberty. 
The muscles become rigid and fixed when an attempt is made to move 
them. The lack of voluntary control of the muscle is seen in slow con- 
traction and relaxation when voluntary efforts are made. The rigidity 
may wear off and the limb can then be used. It is particularly 
noticeable when walking is attempted; as the leg is advanced slowly it 
may remain stiff for a second or two, but after it becomes limber the 
patient can walk for hours. If he stops walking the same difficulty is 
experienced when it is resumed. Both the arms and the legs are 
affected. Patients are usually well nourished, however. There are no 
atrophies. The muscles are irritable, so that mechanical stimulus or 
pressure causes tonic contraction. Movement and cold aggravate it. 
Sensation and reflexes are not affected, and there is no evidence of dis- 
ease of the cerebro-spinal system, save the occurrence of hypochondri- 
asis in some cases. The myotonic reaction described by Erb is induced. 
(See electrical diagnosis — Diseases of the Nerves.) 

Paramyoclonus Multiplex. In this affection there is clonic con- 
traction of the muscles. It is usually confined to the extremities, and 
occurs in paroxysms. It may have been caused by sudden twitching or 
violent motion. The clonic spasms at first do not interfere with the 
patient's occupation, but gradually increase. Both legs are affected and 
the contractions vary from 50 to 150 in the minute. The contractions 
may be rhythmical. In severe cases the muscles of the back and abdo- 
men contract violently. Tremors of the muscles may be present in the 
intervals. (For spasm, tremor, contraction, etc., see Nervous Diseases.) 



138 



GENERAL DIAGNOSIS. 



Myositis. Inflammation of the muscles. (For changes in the mus- 
cles due to trichinosis, see that disease.) In inflammation of the muscle 
there is pain, swelling, and loss of power. In universal myositis the 
inflammation begins in the muscles of the lower extremities and gradu- 
ally involves other muscles of the body. The muscles are swollen, 
hard, and painful on pressure. Atrophy supervenes in groups of mus- 
cles. The progress is gradual, and death ensues from involvement of 
the respiratory muscles. The muscles may become stiff and more or 
less rigid. Local cedema of the skin over the muscle occurs. 

The three cardinal symptoms that attend the disease as described by 
Loenfeld are: (1) Swelling of the extremities due to subcutaneous 
oedema and swelling of the muscle, on account of which there is dis- 
turbance of function ; (2) extension to the muscles of respiration and 
deglutition ; (3) a more or less extensive eruption. The latter is ery- 
thematous, its distribution is usually general but irregular, and may 
be followed by pigmentation. The disease must not be confounded 
with trichinosis. In the latter, examination of a small portion of mus- 
cle discloses the trichina?. Progressive ossification of the muscles is 
rare. The muscle tissue undergoes gradual ossification, either in local- 
ized spots or in widespread areas. Inflammation of the muscle precedes 
the ossification. As the inflammatory swelling subsides, the muscles 
become hard and are gradually converted into bony tissue. The disease 
lasts over a great number of years. 



Raymond's Table of Atrophies. 



Circumscribed atrophies 



Progressive atrophies . 



{Atrophy from compression. 
Atrophy in inflammatory conditions (pleurisy, joint disease, etc.) 
Atrophy from injury or inflammation of individual nerves. 

f Progressive spinal muscular atrophy ; type Aran-Duchenne. 

f Pseudo-hypertrophic muscular paralysis. 
I Type Leyden-Mobius. 
\ Progressive myopathic J Type zimmerlin. 

atrophy j Type Erb- 

Type Landouzy-Dejerine. 
[_ { Type Charcot-Marie. 



Diffuse atrophies 



_j Anterior poliomyelitis ■{ 



Facial hemiatrophy . . 

Muscular atrophies of cere- 
bral origin 

Muscular atrophy in hysteria 
Muscular atrophy from sys- 
temic disease of the cord . 

Atrophy complicating other 
disease of the cord . . . 



Syringomyelia. 
( Multiple neuritis 



f Infantile form. 

I Acute of adults : spinal paralysis, with 
rapid course and curable (Landouzy- 
Dejerine); subacute and chronic form; 
chronic mixed form (Erb); diffuse sub- 
acute, general spinal paralysis (Du- 
chenne). 



(amyotrophic form) . 



Lead paralysis. 
Leprous neuritis. 
Alcoholic neuritis. 



With secondary degeneration involving the anterior cornua. 
Without secondary degeneration involving the anterior cornua. 

Amyotrophic sclerosis. 
Glosso-labio-laryngeal paralysis. 

Atrophy in myelitis. 
Atrophy in compression of the cord. 
Atrophy in multiple sclerosis. 
Atrophy in tabes dorsalis. 



THE DATA OBTAINED BY 



OBSERVATION. 



139 



The Bones. The examination is made by inspection and palpation. 
The student should familiarize himself with the shape of the bones 
and the seat of normal tuberosities. He should learn the movements 
of the spine and its position in health. Examination is usually made 
to determine their position and shape, and, in addition, to ascertain the 
presence of local changes. 

Local Changes. Changes in the bone that appertain to general 
changes of the skeleton have been referred to. Local examination of 
the bones, however, is of the greatest importance. The discovery of a 
slight change may lead to the recognition of a grave general process. 
We examine for local inflammation and the presence of nodes. Simple 
local inflammation or periostitis may be due to syphilis, and is recognized 
by local pain, swelling, and slight oedema. It may be diffuse. It is 
seen most frequently on the tibia, sternum, and clavicle. Nodes form 
on various portions of the skeleton, but are most frequently seen on 
the skull, and of this region the forehead; or on the shafts of the long 
bones, preferably the tibia, ulna, and clavicles. They are usually mul- 
tiple or bilateral. They are not so hard and dense as exostoses. The 
latter are situated on the outer aspects of the bone and in relation to 
tendons or muscles which are characterized by vigor of action. 

As an illustration of the importance of recognizing nodes the writer 
has seen a case of persistent headache, the true nature of which was only 
ascertained by finding a small node on the skull. The headache had 
been of long (five years) duration, and treatment for it sought in many 
countries. 

Tenderness of the sternum upon pressure is often of diagnostic signifi- 
cance and usually indicative of syphilis. The pain and tenderness just 
noted, however, must not be confounded with local tenderness due to ne- 
crosis which often arises in the convalescence of fevers, notably typhoid. 

Position and Shape. The peculiar position (falling downward) 
assumed by the scapula in paralysis of the serratus magnus is diagnostic 
of that affection, and indicates disease of the posterior thoracic nerve. In 
examination of the clavicles fractures must not be taken for disease of the 
bone, of which rickets is the most common. The examination of the spinal 
column is of the greatest importance. (See Spinal Joints, next chapter.) 
It is not within the province of this work to include the study of the 
diseases of the spinal column due to caries from tuberculosis. Observa- 
tion of all patients is, however, not complete without noting the mova- 
bility of the spine and the presence or absence of curvature. I refer 
to the curvature due to weakness of groups of spinal muscles. Without 
doubt functional disorders of the gastro-intestinal tract and of the uterus 
are intensified by the presence of curvature, which leads to deformity of 
the body and hence the assuming of improper positions when sitting or 
walking. To recognize the lateral or anterior curvature is to be able to 
put the patient on lines of treatment which otherwise would not be fol- 
lowed, but without which weak muscles, improper aeration of blood, and 
sluggish circulation would persist. The occurrence of pain in the dis- 
tribution of nerves, or at their termini, is often due to spiral caries 
pressing on them as they pass through the foramina. The most notice- 
able is the pain about the umbilicus in children, due to Pott's disease. 



140 



GENERAL DIAGNOSIS. 



The bones and cartilages connected with the thorax will be considered 
under Diseases of the Lungs. 

Osteomyelitis. The occurrence of high fever, with or without chills 
but usually with pyamnic symptoms, should conduct inquiry to the bones, 
which must be examined carefully. A spot of tenderness followed sub- 
sequently by local redness and swelling — on the tibia, for instance — 
would indicate the seat of suppuration in osteomyelitis. 

The Joints. By inspection and palpation, changes in the joints are 
observed which are of great significance in the recognition of various 
morbid processes. 

Inspection. The size, shape, and color are observed, and the posi- 
tion assumed noted. In addition, the movability of the joint is inves- 
tigated. The nature of the joint affection is learned further by knowl- 
edge as to the number of joints affected, the limitation to large or 
small joints, the occurrence of metastasis. Polyarticular inflammation 
of small joints points to rheumatoid arthritis ; of large joints, to rheu- 
matism ; monarticular inflammation of small joints, to gout ; of large 
joints, to gonorrhceal rheumatism or pyaemia; sudden flitting from one 
joint to another is characteristic of rheumatism. 

The Size and Shape. The joints may be enlarged. The enlarge- 
ment may be due to infiltration of the tissues about the joints, to effusion 
within the joints, serous or purulent, or inflammation of the ends of the 
bones. 1. When the enlargement is due to infiltration about the joint, 
the tissues are previously thickened, as indicated by palpation, and the 
outline of the joint is changed. The normal contour is lost entirely, and, 
instead, a globular swelling beginning above, and extending below the 
joint is seen. 2. When enlargement is due to effusion it may be detected 
by palpation, by which fluctuation is secured. This is particularly so in 
the large joints. If it is the knee, the patella will float. The effusion 
changes the normal contour, but in the earlier stages may cause local 
swellings at parts where the synovial sacs are near the surface ; hence, 
at the articulation of the tibia and fibula with the tarsus on the inner 
and outer side, a baggy swelling is observed. At the knee the swelling 
is on each side above or below the patella. Where effusion is great the 
joint becomes immobile, and may be flexed on account of distention of 
the sac. 3. When enlargement of the joints is due to hypertrophy of 
the bones, the latter are thickeued and very hard. There may or may 
not be, and usually is not, fixation, and movement is but moderately 
interfered with. 

Changes in the outline of the joint are seen in addition to the above in 
rheumatoid arthritis. The loss of the cartilaginous substance of the joint, 
with the secondary osteophyte changes, cause distortion, so that in the 
case of the small joints of the finger subluxation is seen ; similar sub- 
luxations are seen in larger joints likewise. The ends of the phalangeal 
bones are thickened. Change in the color is usually noted in inflamma- 
tions. Its surface is bright red or dusky. 

The position assumed is of diagnostic importance. Flexion of the 
limb of the affected joint occurs in overdistention. In rheumatoid 
arthritis there is subluxation. Immobility is observed. (See Palpation.) 



THE DATA OBTAINED BY OBSERVATION. 



141 



Palpation. The results of inspection are confirmed. 1. The 
niovability of the joint is learned. In inflammation it is attended by 
pain; movement is inhibited. A reflex spasm takes place if osteitis and 
cartilage destruction are present. The spasm prevents movement. In 
effusion there is less or even no movement whatever. In rheumatoid 
arthritis movement is prevented by the osteophytic growths which sur- 
round the joint. 

By palpation fluctuation is detected, pointing to swelling on account 
of effusion. Pitting on pressure is found in suppuration of the joint. 

In rheumatoid and other destructive diseases, a crepitus or grating 
sensation is observed. 

The subjective symptoms of joint affections are worthy of note. Pain 
is the most prominent. This may be spontaneous or may arise upon 
pressure, or be due to attempts at movement. Spontaneous pain with 
tenderness is more pronounced in rheumatic and gouty inflammations of 
the joints. The pain is usually worse at night. This is particularly 
the case in tuberculous joints, and is due to removal of the apprehensive 
spasm of the muscles whereby the joints had been protected. 

The pain in the joints must not be confounded with the pain that 
attends local or multiple neuritis. I have seen the pains of neuritis 
attributed to rheumatism of the phalanges, tarsus, and ankle, until paral- 
ysis of the extensors took place. I have seen the pain of neuritis of 
the circumflex taken for shoulder-joint disease. Multiple neuritis is 
attended by pains that may be located in the joints by the patient; but 
whether local or geueral neuritis, the joints are never swollen, tender, or 
painful on movement by the hand. 

The Joints of Rhachitis. (See under Rhachitis.) 

The Joints of Osteo-arthritis. (See under Skeleton.) 

The Joint of Synovitis. The inflammation is recognized by 
pain, heat, redness, and swelling. Effusion is present, physical signs 
of which are readily elicited. It may be due to traumatism, but the 
inflammations due to internal morbid processes concern us. The most 
common are tuberculosis, pyaemia, and gonorrheal infection when sin- 
gle joints are affected. A mild degree of inflammation may be limited 
to one joint in subacute rheumatism. In tuberculosis the joint is 
swollen and the neighboring tissues oedematous. Effusion may be 
detected. There is fever. The hip, the knee, the elbow, the wrist 
and the ankle are most frequently affected. Cheesy material may be 
withdrawn by tapping. Destruction ultimately takes place, with sub- 
luxations and subsequent fixation of the joint. With the fever, wasting 
and other signs of tuberculosis, and the occurrence of tuberculosis in 
some other portions of the body, point to the true nature of the affec- 
tion. The tuberculous process may be limited to the affected joint, or 
secondary tuberculosis may supervene. 

The Joint of Gonorrheal Rheumatism. Signs of acute or sub- 
acute inflammation are present with oedema and effusion. The patient is 
a male in whom an acute or chronic urethral discharge is found. The 
pain is worse at night. The process is of long duration. Metastasis does 
not take place. Destruction rarely occurs, but ankylosis may follow. 
General pysemic symptoms may ensue, and ulcerative endocarditis 



142 



GENERAL DIAGNOSIS. 



supervene. There is entire absence of heart symptoms from simple 
endocarditis. The general and. local signs of rheumatism or of a rheu- 
matic diathesis, and changes in the urine, skiu eruptions, cardiac lesions, 
etc., are wanting. 

The Joint of Gout. Any joiDt may be affected, but the typical 
gouty inflammation is seen in the metaoarpo-phalangeal joint of the 
great toe — the ball of the toe There is great swelling, intense redness, 
enlargement of the veins, and oedema. There may be some effusion ; 
it results in chronic inflammation and enlargement of the joint. Tophi 
about the joints are observed. Agonizing pain occurs, and is worse at 
night. Fever attends the process. The attack is of short duration, 
and may be followed or attended by acute gouty inflammation of other 
structures, or vascular and renal changes associated with this general 
morbid process. 

The Joint of Rheumatism. It is swollen, painful both spon- 
taneously and on movement, and there may be some redness of the 
surface. Other joints are soon attacked, with subsidence of the symp- 
toms in the original joint. The large joints are usually affected. It 
may be limited to one side or may affect both. Secondary or concurrent 
cardiac inflammations may be noted. High fever and acid sweats attend 
the process, which is common in both sexes in childhood and early adult 
life. Other evidences of the rheumatic diathesis and the history of 
previous attacks point to the true nature of the joint swelling. 

The Joint of Rheumatoid Arthritis. There may be simple 
chronic inflammation with acute exacerbations, or prolonged subacute 
inflammation. The small joints are affected first, as the phalanges. 
They are swollen and the adjacent structures infiltrated. At first there 
may be, particularly with each exacerbation, some effusion. Later the 
cartilages are eroded, and crepitus and grating are detected on palpation. 
Subluxation with great deformity ensues, followed bv complete fixa- 
tion of the joint. The crepitation may be detected along the sheaths of 
the tendon. Osteophytes develop. The skin over the surface becomes 
glossy, and the affected hands are covered with freckles. Occurring in 
early adult life, usually in females with marked anaemia and secondary 
wasting of the muscles without heart lesion or general indications of 
rheumatic or gouty diathesis, the true nature of the swelling is early 
recognized. (See Rheumatoid Arthritis — Extremities.) 

The Tabetic Joint. In forms of nervous diseases, particularly 
in sclerosis of the posterior columns, secondary joint involvement some- 
times follows. The change in the large joints is first preceded by pain, 
stiffness, and inability to use them. Gradually nutritive changes take 
place. At first there is boggy swelling. The cartilages become eroded, 
the heads of the bone waste, the ligaments ossify, and irregular bony 
growths project. Wasting of the head of the femur is followed by 
dislocation. Sometimes an effusion takes place in the joints, and there 
may be peri-articular oedema. The large joints are most commonly 
affected — the knee, hip, ankle, and elbow. Injury excites the abnormal 
trophic process. When the tarsal bones and the articulations are affected 
the foot becomes flat, and the tarsal and metatarsal articulation and the 
tarsal bones project forward or backward. This is called the tabetic foot. 



THE DATA OBTAINED BY OBSERVATION. 



143 



The Joint of Hysteria. Symptoms referable to the joints are 
sometimes complained of in listeria. Pain and fixation of the joint are 
complained of. The joint rarely undergoes organic changes, but some- 
times a plastic infiltration of the connective tissue outside of the capsule 
does occur. The hysterical nature of the pain and immobility are recog- 
nized by the absence of a cause for joint lesion, the absence of fluctuation, 
or of signs due to erosion, by the association of the local symptoms with 
the phenomena of hysteria, but more particularly by the fact that contrac- 
tion and even wasting precede the joint symptoms. In true affections of 
the joint both occur after the joint has become diseased ; in hysteria 
muscular contraction will take place first. 

The knee is the joiut usually affected. Care must be taken not to be 
deceived by local vasomotor changes of hysterical origin which may be 
observed over the surface of the joint. This local increased temperature is 
not associated with general fever, however, while the vasomotor changes 
indicated by swelling of the skin, increased tension, and the shining 
appearance, with increased sensibility, are not persistent, but occur once 
or twice in the twenty-four hours. In a remarkable case of Mitchell's 
the local vasomotor change took place at night. The temperature of 
the knee which was affected would increase three or four degrees, while 
the pulse remained at 80. The local symptoms of heat, redness, swell- 
ing, tension, and increased pain would pass away by three o'clock in the 
morning. The fact that the same symptoms could be brought about by 
handling the knee, or by pressure upon the patella, pointed to its vaso- 
motor origin. 

In joint cases, as was the case with the one just noted, a study of the 
reflexes is made. The reflexes do not change, electrical reactions are 
normal, although there may be atrophy from disuse, but not to the degree 
that occurs in organic disease. The muscles were contracted, but, as 
previously noted, the contracture was primarily a relaxation, which took 
place if the tension was removed. Concerning these vasomotor changes, 
Sir James Paget's expression, "A joint which is cold by day and hot 
by night is not an inflamed joint," is a safe guide to the recognition of 
a joint affection. When the joint becomes hysterical after injury it is 
most difficult accurately to ascertain its true nature. 

Special Joints. The three joints that should concern the student 
more particularly are the shoulder, hip, and knee. When symptoms are 
referred to either of these joints they should not be passed over lightly. 
Grave consequences have followed attributing inflammation of the hip- 
joint to rheumatism when it was of tuberculous origin. But not only 
has hip-joint disease been mistaken for rheumatism, but the mistake has 
been made of considering the process to be going on in the knee instead 
of the hip. This has arisen because there is often flexion of the leg and 
because pain is so often referred to the knee-joint. 

On the other hand, cases of hip-joint disease have been mistaken for 
suppuration in the pelvis or in the iliac fossa. Typhlitis or appendi- 
citis has frequently been mistaken for hip-joint disease. 

In the shoulder-joint the danger is in confounding neuritis of the cir- 
cumflex nerve and consequent paralysis of the deltoid with affections of 
the joint. If it takes place about the joint and there is inability to move 



144 



GENERAL DIAGNOSIS. 



it upon the part of the patient, it is still readily moved by the physician, 
and the physical signs of joint inflammation are wanting when sought 
for. 

Method of Examination. In the examination of bones and joints, 
particularly the spinal column, it is necessary that the patient should be 
stripped, and in addition to noting the movements in the upright, or 
semi- upright posture, as well as positions assumed in each, the position 
of the trunk and of the joints should be examined with the patient lying 
down. A hard, smooth surface should be selected. In this manner 
deformities, changes in the length of the bone, and abnormal posture can 
be carefully observed. In addition we must note muscular wasting, the 
occurrence of local tenderness aud swelling, changes in the length of the 
bones, changes in the movements of the joints, and loss of other 
functional activity causing lameness or joint disability. 

Diagnostic Significance. The diagnostic significance of the dis- 
tribution of the lesion in joint affections is of great importance. Lesions 
may be unilateral or bilateral, and may be symmetrical or asymmetrical. 
They may be limited to the small joints or to the large joints alone. 
Bilateral joint lesions are characteristic of rheumatoid arthritis. In 
such disease, moreover, the small joints are particularly involved. In 
gout the small joints are primarily affected, though the large joints may 
become affected secondarily. In rheumatism, on the other hand, larger 
joints are first involved. This affection is particularly specialized by the 
occurrence of asymmetrical inflammation in many joints, the irregularity 
of its distribution and the fugaceous nature of the joint affection. 
Monarticular inflammation is seen in gonorrhoeal rheumatism. In 
pysemia the large joints are involved. The range of movement and 
the evidences determined by palpation are not of marked diagnostic 
significance. In all joint affections the movement is limited and pain- 
ful, upon both active and passive movement. 



CHAP TEE IV. 



BACTERIOLOGICAL DIAGNOSIS. 

Causal relation of bacteria to disease. Koch's laws ; value in diagnosis. Method of 
research : Microscopical examination, cultivation, inoculation. Essentials in 
technique. — Bacteria : Saprophytes, parasites, pathogenic, non-pathogenic, aero- 
bic, anaerobic, facultative anaerobic. Morphology : micrococci, bacilli, spirilla. 
— Micrococci. Morphology : Form and size. Reproduction, fission ; grouping. 
Biological characters : Non-motile. Pigment production. Liquefaction of gela- 
tin. Production of acids. Toxic ptomaines and toxalbumins — Bacilli. Mor- 
phology : Form and size Reproduction, fission, spores ; grouping. Biological 
characters : Motility. Pigment production. Liquefaction of gelatin. Produc- 
tion of acids. Putrefaction, fermentation. — Spirilla. Morphology : Form and 
size. Reproduction, fission; grouping. Biological characters: Motility. 
Pigment production. Liquefaction of gelatin. Production of acids and fer- 
mentation wanting. — Method of research: Blood, discharges, exudations; mode 
of collection. Apparatus. Preparation of apparatus. Sterilization. Micro- 
scopical examination : Technique, cover-glass preparations. Methods of 
staining ; spores. " Hanging drop." — Cultivation of micro-organisms. Culture 
media. Tube and plate cultures. Smear and stab cultures. — Inoculation of 
animals. — Special bacteriological diagnosis. 

It had long been surmised that micro-organisms had much to do with 
morbid processes, and that this relationship was that of cause and effect. 
It was known, for instance, that suppuration, surgical fever, erysipelas, 
hospital gangrene, and puerperal fever were associated with conditions 
which favored the multiplication of the lower forms of life. What 
relationship the micro-organisms bore to the various affections was not 
known. Least of all were the specific micro-organisms which were the 
causes of particular specific morbid processes known. I have said that 
it was surmised; but there was groping about, a difference of opinion, 
a maximum of theory, a minimum of fact. It is true that in relapsing 
fever the spirillum had been found, and that none had been found in any 
other disease. Moreover, it is true that monkeys had been inoculated 
and the disease reproduced in them. It is true the bacillus of anthrax 
had been seen in the blood, in the early " sixties." It is true that the 
great genius Pasteur had prosecuted studies of bacteria in animal and 
vegetable pathology to most brilliant and practical conclusions. Never- 
theless, there was confusion and doubt ; scientists were not satisfied 
with the demonstrations which undertook to prove the causal relation- 
ship of micro-organisms to disease. 

Laws to Establish Causal Relationship. Through the 
genius of Robert Koch theories and objections were set at naught. 
The scientific world was fully prepared by the labors of early investi- 

10 



146 



GENERAL DIAGNOSIS. 



gators to accept Koch's conclusions. They were based upon an array of 
well-formulated facts, which anyone could prove for himself. Koch's 
laws were, in substance, that in order to assert that a specific micro- 
organism is productive of disease we must demonstrate, first, its con- 
stant presence in the fluids or tissues of the individual subject to that 
disease ; second, its absence from all other diseases ; third, its isolation, 
growth, and repeated cultivation on proper culture media ; fourth, its 
power of reproducing the disease after inoculation in susceptible animals. 
The experimental circle was then repeated. In this manner the causal 
relationship of micro-organisms to special diseases had been proven by 
the distinguished investigator in the case of anthrax, tuberculosis, and 
other affections. Unfortunately there has been limitation to the 
researches, because of the difficulty, among others, of finding animals 
that are susceptible to inoculation with some of the micro-organisms 
capable of producing disease in man. 

Aid to Diagnosis. It is readily seen that when the definite cause 
of an infectious disease has been isolated and the morphological and 
biological properties of the causal micro-organism studied, the clinician 
has acquired a valuable aid to diagnosis. Indeed, in such affections, 
diagnosis has become an absolute certainty. 

Method of Research. The diagnosis to be complete must include, 
(1) the finding of the specific micro-organism in the blood or tissues 
of the subject or in the pathological secretions or excretions ; (2) the iso- 
lation and cultivation of the micro-organism ; (3) the inoculation and the 
reproduction thereby of the disease in animals. In many affections the 
morphological properties of the micro-organism are such that the finding 
of it is sufficient to establish a diagnosis. On the other hand, in some 
affections, the absence, or. rather failure of detection, of the micro- 
organism in the fluids or discharges is not proof that the disease is not 
present in the suspected individual, in whom symptoms and lesions 
point to a specific micro-organism. The affection tuberculosis well 
illustrates the propositions in the last two sentences. If the bacillus is 
found in the sputum of a suspected case the diagnosis is established 
definitely, and no further procedures for diagnostic purposes are neces- 
sary. In other clinical forms, as tuberculous pleurisy, or empyema, 
or glandular or joint tuberculosis, the micro-organisms are few and dif- 
ficult to find. Cultures, or more conclusive still, inoculations, must be 
resorted to, often, before a final conclusion can be arrived at. It is pos- 
sible that spores alone exist — morphological elements difficult to detect 
by staining and microscopical methods, but which may rapidly multi- 
ply under favorable culture or inoculation conditions. Again, micro- 
organisms have been found in certain affections, and although thus far 
their causal relationship to the latter has not been fully proven, never- 
theless their constant occurrence in the special affection and in that one 
alone, renders their presence of high diagnostic value. Thus the amoeba 
of dysentery and the plasmodium malaria? of Laverau are diagnostic of 
their respective affections. 



BACTERIOLOGICAL DIAGNOSIS. 



147 



Essential Knowledge. For diagnostic purposes, bacteriological research 
must be conducted in accordance with the methods of bacteriology. 
Such researches are possible at this time, because of, 1, the high degree 
of development and mode of use of optical apparatus, including oil- 
immersion lenses, Abbe's condenser, and diaphragms; 2, the develop- 
ment by Weigert of the effect of aniline dyes on protoplasm, and the 
property of micro-organisms of taking different stainings ; 3, of the 
principles of sterilization by heat, by which foreign micro-organisms 
are excluded ; 4, of the use of solid culture media, and the plate method 
of obtaining pure cultures suggested by Koch. 

Bacteria. Varieties. Bacteria are of two classes. One class 
obtain subsistence from dead organic matter, breaking it up into such 
simpler forms as carbon dioxide, ammonia, etc. They act to some 
degree as scavengers, and are beneficial rather than harmful. Such 
are called saprophytes. The second class live at the expense of higher 
forms of life, and at the same time produce very poisonous substances. 
They are called parasites, and are or are not essentially harmful. We 
are concerned with the harmful varieties. They imply the presence of a 
host in which they develop. They may enter the blood. Diseases to which 
they give rise are known as infectious diseases. The process they set 
up may be local, as in gonorrhoea or certain skin affections, or general, as 
in typhoid fever, syphilis, or tuberculosis. In some instances it is first 
local and then becomes general, as in tuberculosis. Their clinical mani- 
festation is seen in the infectious diseases. Sometimes certain bacteria 
of one class may acquire the power of living like those of the other 
class, and are then called facultative saprophytes or parasites. They 
develop in cavities of the body. They may enter the blood. They 
produce in certain cases particularly poisonous substances which enter 
the circulation and cause an intoxication, to which the term saprmmia 
or toxcemia is applied. Parasites and facultative parasites include those 
bacteria that are productive of disease, and are therefore known as patho- 
genic bacteria. All bacteria require certain conditions and certain ma- 
terials for their development. All require carbon, nitrogen, and water, 
and a certain temperature, which varies in each case. Some require 
oxygen and are called aerobic; others cannot grow in the presence of 
oxygen, and are called anaerobic. Others grow either with or without 
oxygen. These are called facultative anaerobic. 

Morphology and Biological Characteristics. To determine 
the micro-organism which may be the cause of the disease under exam- 
ination the student must be familiar with the morphology and the 
biological properties of the various forms. By these means a distinction 
between them is possible, and a bacteriological diagnosis made. The 
morphology. The shape, the size, the mode of reproduction and grouping 
are to be studied. Bacteria or fungi are divided morphologically into 
micrococci or spherical bacteria, bacilli or rod-shaped bacteria, and spirilla 
or twisted forms. Bacteria procreate by simple fission, and are therefore 
known as fission fungi or schizomycetes. Some forms also produce 
spores. The biological properties include motility, color, the growth on 
various culture media, and under various temperatures, and the products 



148 



GENERAL DIAGNOSIS. 



of vital activity. The growth on various culture media will be consid- 
ered under each pathogenic bacterium which it is the province of this 
work to discuss. On the character and extent of this growth, its color 
and other properties, data are collected by which the various micro- 
organisms are distinguished. Some properties which do not belong to 
pathogenic bacteria will not be considered, as the production of phos- 
phoresence, the production of marsh gas, hydro-sulphuric acid, viscous 
fermentation, and the fermentation of urea. 

By the above we can sufficiently identify the pathogenic bacteria for 
our present purpose. 

Micrococci. Morphology. To this group belong the spherical 
bacteria. Each coccus is of equal diameter in all directions. They vary 
in size from 0.1 v to 1 or 2 p. A micromillimetre (>) is one twenty-five 
thousandth of an inch. The various micrococci resemble each other so 
much in form and size that they cannot be distinguished by their micro- 
scopic appearances. To distinguish them, dependence must be placed on 
the color and character of their growth in various culture media, patho- 
genic power, and other biological differences. The mode of grouping 
after fission or reproduction is an important characteristic by which 
varieties are differentiated. J ust before dividing, they are not exactly 
spherical, but short or long oval. After division, the staphylococci (for 
they divide indefinitely) are solitary or in pairs, or occasionally in groups 
of four, or in clusters roughly likened to a bunch of grapes. The organism 
is a dip/ococcus when associated in pairs. Sometimes two or four are in- 
cluded in a capsule. Zooglcece are groups of cocci held together by a trans- 
parent glutinous substance. Streptococci are characterized by grouping 
in chains, known as chaplets, or torula chains, because division takes 
place in one direction only. When division takes place in two direc- 
tions, groups of four, or tetrads, are formed ; and when in three directions, 
groups or packets of eight are formed, of which the sarcince are the 
most familiar examples. 

Biological Characteristics. Micrococci are not motile and do not 
form spores. Products of vital activity. The distinction of the various 
forms of bacteria is also made by noting the difference in the products of 
vital activity. Of these, pigment production is one of the most apparent. 
The staphylococcus pyogenes aureus and citreus are chromogenic or pig- 
ment-producing bacteria. The liquefaction of gelatin, when cultures are 
made, is a biological characteristic which points to the diagnosis of the 
various species. Some pathogenic as well as non-pathogenic germs 
thus act toward the nutrient medium ; others of both classes do not 
affect it. A peptonizing ferment is formed during the growth of the cells, 
which acts upon and dissolves the gelatin. The amount, degree, and 
form of liquefaction serve to distinguish various species. The staphylo- 
coccus pyogenes aureus and albus (as well as others) are liquefying 
micrococci. Production of acids. In the growths of bacteria, many 
produce an acid — lactic acid, acetic acid, butyric acid — which gives an 
acid reaction to the culture media. This may be seen if a neutral litmus 
solution has been added to the gelatin. The pink color produced in- 
dicates the presence of an acid. Culture media, it must be remembered, 



BACTERIOLOGICAL DIAGNOSIS. 



149 



are alkaline or neutral. The pathogenic micrococci which produce an 
acid are the staphylococci of pus — lactic acid. 

Putrefactive fermentation is set up by bacilli and not micrococci. 
Other products of vital activity need not concern us, as they are produced 
by non-pathogenic forms. 

Toxic ptomaines and toxalbumins are products of many forms of 
pathogenic bacteria, and are the cause of the symptoms of the infective 
diseases in many instances ; thus in diphtheria, the local infective inflam- 
mation is due to the bacillus ; the general symptoms are due to the 
toxalbumin. The isolation and detection of the toxalbumins are not 
sufficiently easy to warrant such mode of investigation for diagnostic 
purposes. Often the results of inoculation, by which the lethal effect is 
produced, aid in the diagnosis of the suspected ailment. 

The Bacilli. Morphology. The bacilli or rod-shaped bacteria 
differ widely in form, in size, and in modes of grouping after fission. 
Form and size. The longitudinal diameter is greater than the trans- 
verse, and the forms vary from short oval or slender rods to long 
filaments; sometimes short rods and long filaments are seen in pure 
cultures of the same bacillus, as in the typhoid bacillus. The transverse 
diameter does not vary, as a rule. The form of the extremities of the 
rods must be observed. They may be square, slightly rounded, round, 
oval, or lance or spindle shaped. Reproduction and grouping. Fission 
or reproduction takes place by binary division, transverse to the longi- 
tudinal axis. They group in long chains, or are solitary, or united in 
pairs. They may be surrounded by a capsule or collect in zoogloea 
masses. 

Spores. When conditions unfavorable to continuous multiplication 
by transverse division arise, certain bacilli possess the property of enter- 
ing into a permanent or resting stage. In this case there develops 
within the body of the bacillus an oval, egg-shaped structure — an 
endogenous spore. The spore represents the inactive stage, and lies 
dormant until circumstances favorable to growth reappear, when it 
develops into a bacillus identical with that from which it was formed. 
Spores do not develop into spores, but into bacilli. The spores retain 
their vitality for months or years, and resist desiccation. They are 
spherical or oval, and highly reproductive. They are formed by 
condensation of protoplasm at the centre or at one end of the bacillus, 
where they are retained in a linear position until set free. Some bacilli 
grow into long filaments during spore formation ; others change their 
shape, swelling at the centre, becoming spindle or club shaped, accord- 
ing to the location of the spore within it. Many bacilli do not change 
their shape at this stage. The spores are free or collected in masses 
with the bacilli as well as located in the parent bacillus. 

Motility. The bacilli are often actively motile, because of the pres- 
ence of flagella. The movement is one of progression in different direc- 
tions. It may be slow and deliberate, in a to-and-fro motion, or 
serpentine, or a quick, darting forward motion. 

Biological Characters. Products of vital activity. They may 
be ascertained in the same manner as in the study of micrococci. Pigment 



150 



GENERAL DIAGNOSIS. 



production is seen in cultures of the bacillus pyocyaneus or bacillus of 
green pus, of which there are several varieties producing various shades 
of blue or fluorescent green. Liquefaction of gelatin. This is produced 
by the bacillus anthracis and the bacillus pyocyaneus. Production of 
acids. The bacillus coli communis produces lactic acid. Putrefactive 
fermentation. The latter bacillus sets up fermentation. 

The Spirilla. Morphology. They are seen in the form of curved 
rods or spiral filaments. The shorter ones are curved, the longer are 
spiral, like a corkscrew. The curved filaments may be short and rigid, 
or long and flexible. 

Reproduction. They reproduce by binary division (fission). 

Biological Characters. Motility. They are motile; the move- 
ment is rotary, as well as progressive in the direction of the long axis of 
the filament. The presence of flagella is determined by Loflfler's 
method. They are single at the ends of rods, or several are seen at 
one extremity, or they are around the entire periphery. Pigment pro- 
duction. Pathogenic spirilla do not produce pigment. Liquefaction of 
gelatin. The spirillum of cholera Asiatica (comma bacillus), and the 
spirillum of cholera nostras (Finkler and Prior) each liquefy gelatin in 
a peculiar manner. 

Methods of Research. Having learned the morphological and 
biological characters of the various forms of pathogenic bacteria, the 
student is prepared to render such knowledge useful for diagnostic 
purppses. I have said that methods of bacteriological research must 
be employed; the following account is to embrace the steps that should 
be taken to ascertain the presence of a micro-organism in the blood, 
the secretions or excretions, the fluids of cavities or cysts (exudations, 
transudations, and cystic fluids). In a case the character of which is 
unknown, and in which there is no distinctive pathological discharge or 
reproduction, all fluids of the body must be examined. In other cases, 
the pathological discharge (pus), or perhaps diseased tissue, must be ex- 
amined. We derive a clue as to the direction which the examination 
is to take by the nature of the symptoms. In cases of pulmonary 
disease, the sputum ; of faucial disease, the membrane, pus, or other 
secretions from the fauces ; in intestinal disease, the discharge from the 
bowels, and in' genito-urinary disease, the urine. It must not be for- 
gotten that in many, even highly fatal diseases, the blood is not invaded 
by micro-organisms. Death is due to the development of toxic sub- 
stances. Hence, as in cholera or diphtheria, the presence of the micro- 
organism is not sought for in the blood, but in the specific excretion or 
exudation. 

The method of procedure is : 1. Microscopical examination of a minute 
particle of the stained and unstained blood or the morbid secretion or 
excretion. 2. Cultivation of the micro-organisms on plates. 3. Inocu- 
lation of animals w T ith pure cultures of the suspicious organism or 
organisms. 

The Apparatus. The apparatus necessary to the simplest bacterio- 
logical research is as follows : Sterilizers, incubator, glass flasks, covered 



BACTERIOLOGICAL DIAGNOSIS. 



151 



dishes, test-tubes and plates, platinum needles fixed in glass handles, 
cotton, materials for culture media, microscope, with slides and cover- 
glasses, and in addition to lenses of lower powers, a y 1 ^ oil-immersion 
lens, and finally the various stains used. 

Preparation of apparatus. Boil all glassware for half an hour in a 
solution of common soda (4 to 6 per cent.), then scrub thoroughly, rinse 
in warm solution of HgCl 2 (1 per cent.), and then in pure water, drain 
with tops down ; plug tubes and flasks with raw cotton, fitting firmly 
and evenly, so that the cotton can hold the weight of the test-tube ; 
sterilize in dry oven. The test-tubes (plugged) are placed in a rack for 
further use. 

The tubes and flasks are best filled with the culture media through a 
spherical funnel that can be plugged with cotton. Then they are to be 
sterilized in the steam sterilizer as heretofore described. 

The cover-glasses must be thoroughly cleaned by immersion in strong 
nitric acid for a few hours, then rinsed in water, then in alcohol and 
ether. They are then kept in alcohol. 

Sterilization. It should be understood that the first requisite for 
the prosecution of these studies is to secure absolute cleanliness and to 
prevent the invasion of extraneous micro-organisms. The first step 
is thorough sterilization of all appliances required for work, and of all 
the media, to destroy previously existing bacteria. 

The sterilization is best accomplished with steam where the objects to 
be sterilized admit of it. With dry heat, a temperature of at least 
150° C. must be applied for at least an hour, and of course can only be 
used for glassware and metal instruments. All media (see page 154), 
whether solid or fluid, are sterilized by steam. Media which cannot 
withstand long exposure to the necessary heat are sterilized by the inter- 
mittent application of steam. The reason that this is effective is that 
fully-developed bacteria are destroyed at a much lower temperature 
and with shorter exposure than are the spores. One application kills 
the developed bacteria, then the material is kept for a time in an 
incubator, spores develop into bacteria and are easily killed by a 
second application. By repeating this process from three to five times 
the substance is effectually sterilized. If the exposure is made longer 
a much lower degree of heat may be used, so that in the case of blood- 
serum it may be sterilized without coagulating the albumin. Usually 
an exposure of fifteen minutes to steam on each of three successive days 
is used for stable media, and an exposure of an hour on six successive 
days to a temperature of 70° C. for more delicate media, as blood- 
serum. In the intervals the materials must be kept at a temperature 
of 25° to 30° C. A single application of steam under pressure is 
often used, but only very stable materials can be subjected to this with- 
out damage. 

The ordinary " Arnold steam sterilizer " is as good as any. The 
dry sterilizer is merely a metal box with copper bottom and ventilating 
holes. It is well to have an asbestos casing. 

Metallic articles, as forceps, platinum probes, etc., are best sterilized 
in the flame of a Bunsen burner. 



152 



GENERAL DIAGNOSIS. 



Collection of Material. A definite careful method must be 
observed when the pathological product is removed from the patient, 
or collected for investigation (see Chapter V. — Exploratory Puncture). 
Pus and fluids should be placed in sterilized glass bottles or tubes, 
care having been taken that instruments for the removal of the fluid 
were previously sterilized. Exposure to air should be as brief as pos- 
sible. The fluids should not be contaminated with blood or antiseptic 
fluids used for flushing or other surgical procedure. If an abscess is 
opened or purulent peritonitis cut down upon, for instance, tube in- 
oculations can be made at the bedside. The previously sterilized 
platinum point should be kept before use in a test-tube, closed with 
sterilized cotton. It is dipped into the pus, which should be free from 
the blood of the incision, but before it flows over the skin. It is at 
once applied on the media of the test-tube. Sputum should be collected 
in a previously sterilized bottle, or one thoroughly cleansed by boiling. 
The bottle should have a wide mouth. Care must be taken to secure 
sputum from the lungs, and not the secretion from the mouth and fauces. 
Purulent portions, rather than mucoid, are to be sent for examination. 
Blood should be examined at the bedside microscopically, and cultures 
made at the same time. Cover-slip preparations may be made at the 
bedside for future staining. Intestinal discharges may be collected in 
sterilized glass jars and examined as soon as practicable. It may be 
necessary to keep the discharge at the temperature of the body. (See 
Faeces — amoeba dysenterica). 

To secure blood for microscopical study, the finger must be thoroughly 
cleansed with alcohol and puncture made with a sterilized lancet or 
needle. After the blood flows a few seconds it is removed and the 
cover-slip, previously cleansed in nitric acid solution, is gently pressed 
upon the second overflow. Another cover is placed over the blood- 
stained surface of the first slip, the two rubbed together and separated 
by sliding them apart. Sternberg prefers to spread the blood, which 
was collected at the edge of the cover-slip, by drawing a polished glass 
slide, held at an acute angle, over the cover-slip. In either case this 
thin film of blood is allowed to dry, and can be examined later. Stern- 
berg mounts the blood on a glass slide at once. 

Microscopical Examination. The blood and fluids, stained and un- 
stained, and colonies of the preliminary and pure cultures are examined. 
The methods for each as to technique are about the same. The cover- 
slips that are stained must be examined with the oil-immersion objective, 
and the diaphragm of the sub-stage condensing apparatus (Abbe's) open. 
When not stained the diaphragm must be closed. 

The blood may be examined without staining. The bacillus of anthrax 
and the spirillum of relapsing fever may be thus detected. Basic aniline 
dyes are used to stain the cover-slip preparation or the method of 
Loftier or Gram employed. 

The secretions in general are examined by the same method. By 
Gunther's method the spirillum of relapsing fever is detected in the 
blood. Examination of the blood, and the sputum for tubercle bacilli 
and other micro-organisms, will be described in the section on Sputum. 



BACTERIOLOGICAL DIAGNOSIS. 



153 



The examination of the nasal and buccal secretions is described in 
the appropriate chapter. Gram's and Giinther's methods are of value. 
Search for the bacteria in the alimentary tract (see Vomit and Faeces) 
must be made in accordance with methods described in those sections 
and by the methods of staining hereafter described. The urine is 
studied with the Gram and the Friedlander method. The study of 
pus will be described later. 

Examination of Colonies. Just here may be stated the methods em- 
ployed for the study of the morphology of the colonies secured by plate 
and other means of cultivation. The same process applies to the exam- 
ination of pus and pathological fluids. 

Cover-glass preparations are made as follows : On the cover-glass 
place a small drop of distilled water. With a platinum needle take up 
the smallest possible quantity of the colony to be examined, mix it 
with the drop and spread over the surface of glass. Dry under cover 
or by holding with fingers over a flame, the layer of bacteria being 
away from the flame. When dry, pass it with forceps three times 
through the gas or alcohol flame to " fix " the albumin. It is then 
ready for staining. 

Methods of Staining. Many have been devised, but those of 
clinical value are the following : 

1. Aqueous solutions of basic anilines. 

2. Loffler's alkaline methyl-blue. 

3. Koch-Ehrlich's aniline water solutions. 

4. Ziehl's carbol-fuchsin. 

5. Loffler's method of staining flagella. 

6. Gram's method. 

7. Friedlander's method. 

8. Giinther's method. 

1. Basic anilines. Aqueous solutions of the basic aniline colors — 
fuchsin, gentian-violet, and methyl-blue — are used in such strength that 
they can be seen through clearly in an ordinary test-tube. They may 
be kept on hand in bottles with pipettes, or made from concentrated 
alcoholic solutions as needed. They are used by simply dropping a 
few drops on the cover-glass preparation, which is held with the for- 
ceps, allowing it to remain about thirty seconds, and carefully washing 
off in water. It is placed on a slide, bacteria down, and the excess of 
water removed with blotting paper. 

2. Loffler's alkaline methyl-blue solution. Certain bacteria take a 
stain more readily when an alkali has been added. The formula is as 
follows : 

Concentrated alcoholic solution methyl-blue . . . . . . . . 30 c c. 

Caustic potash, 1 : 10,000 100 " 

It is used in the same way as the simple solutions. 

3. Koch-Ehrlich aniline-water solutions. Add to 100 c.c. of dis- 
tilled water, aniline oil, drop by drop, thoroughly shaking after each 
drop, until it becomes opaque. Then filter. Add 10 c.c. absolute alco- 
hol and 11 c.c. of a concentrated alcoholic solution of either fuchsin, 
methyl-blue, or gentian-violet. 



154 



GENERAL DIAGNOSIS. 



4. Ziehl's carbol-fuchsin solution. 

Distilled water 100 c.c. 

Carbolic acid 5 gm. 

Alcohol 10 c.c. 

Fuchsin . . . ... .... 1 gm. 

The use of these various stains will be described in the description of 
the different bacteria. 

5. Loffler's solution for flagella. 

Tannic acid, 20 per cent 10 c.c. 

Cold saturated sol. ferric phosphate . 5 " 

Saturated solution fuchsin . . . . . . . . . . . 1 " 

A few drops of this are placed on the cover-glass coutainiug the 
blood or pus and heated until it begins to steam, and then washed off in 
water. The preparation is then stained with aniline water fuchsin. 
Different bacteria require different reactions, and so a few drops of an 
acid or alkaline solution are added as the case requires. 

6. Gram's method consists in staining with a Koch-Ehrlich solution 
for twenty to thirty minutes, and then decolorizing in 

: Iodine . .1 gm. 

Potassium iodide 2 " 

Distilled water 300 c.c. 

After remaining in this for five minutes, preparations are rinsed in 
alcohol, and the process repeated until the violet color has disappeared. 

For Gunther's and Friedlander's methods, see Sputum. 

To detect spores of bacilli double staining may be employed. The 
preparation is first stained in a hot Ziehl-Neelsen fuchsin solution, then 
decolorized with nitric acid. When stained again with methylene- 
blue, the spores appear red, the bacilli blue. 

The "hanging drop." By the examination of colonies in the hanging 
drop, we learn of the movement of the micro-organism. Place a 
drop of salt solution on a cover-slip, and add a tiny portion of colony 
on platinum wire ; place the slip, drop down, on a glass side in the 
centre of which is a depression or hollow. Fix the slip by applying 
a thin layer of vaselin around the margin of the depression. Care 
must be taken in focussing that the lens does not break the glass, readily 
done because of the transparency. The bacteria are seen in motion ; 
on account of the motion their position is constantly altered. This 
motion must not be mistaken for the Brownian movement of suspended 
particles, which is vibratory from molecular tremor. 

Cultivation of Micro-organisms. The object to be obtained is to 
isolate the pathogenic organism from all other organisms, and to ex- 
clude organisms that may be introduced from without by unclean instru- 
ments or other means. Pure cultures of the fungus are thus obtained. 

Culture Media. Experience has taught us that various forms of 
bacteria require different pabulum, and that various nutrients are 
required for the isolation of different micro-organisms. As to the bacteria 
hereafter noted, we are familiar with the proper soil for their growth. 
The media used for bacteria of clinical importance are : freshly steamed 
potato, gelatin, bouillon, agar-agar, milk, and blood-serum. They are 



BACTERIOLOGICAL DIAGNOSIS. 



155 



prepared or mixed in various ways, and other things may be added, as 
a solution of litmus, to determine the reaction of the bacterial products. 

Bouillon. Lean beef, 500 gm., soaked in one litre of water for twenty- 
four hours in ice-chest ; strain through a coarse towel and press until a 
litre of fluid is obtained. Add 10 gm. of dried peptone and 5 gm. salt. 
Then neutralize with a normal solution (4 per cent.) of caustic soda. 
Boil till albumin is coagulated, filter, and sterilize. 

Nutrient Gelatin. Make bouillon as above (except neutralizing) and 
add 10 to 12 per cent, of gelatin, and neutralize after dissolving it 
by heat. Filter. 

If not perfectly transparent, clarify by heating to 60 to 70° C, add 
whites of two eggs beaten up with 50 c.c. water ; mix thoroughly and 
boil until albumin coagulates ; then filter. Sterilize, and keep in flasks 
or tubes. 

Nutrient Agar. Prepare bouillon complete ; add finely chopped 
agar, 1 to 1.5 per cent. Place in a porcelain-lined iron vessel, mark 
level of fluid, add 250 c.c. of water and boil slowly, with occasional 
stirring for three or four hours. Keep the fluid up to mark by adding 
water. Take the vessel from the fire and set it in cold water. Stir 
until cooled to 68° to 70° C. ; add the whites of two eggs beaten up in 
50 c.c. water. Mix carefully and boil for half an hour, keeping fluid 
up to the level. Filter. 

Sometimes 5 to 7 per cent, of glycerin is added. 

Potatoes. Select old potatoes ; scrub under water faucet with stiff 
brush ; cut out eyes and defects. Then place in 1 : 1000 HgCl 2 for 
twenty minutes. Then place in steam sterilizer and steam forty-five 
minutes. Leave them in and steam fifteen or twenty minutes each day 
for three days. Cut with knife sterilized in flame and lay with cut 
surface upward in a sterilized covered dish. 

Another way of preparing potato is to cut cylinders with a cork 
borer of such size as to fit loosely in a test-tube. A slanting surface is 
then cut from the junction of the first and second thirds of the cylinder 
to the diagonally opposite edge. These are left in running water over 
night, then placed in test-tubes with a cotton plug and steamed for 
forty-five minutes. On the second and third days they are steamed 
fifteen to twenty minutes. 

Milk. It should be sterilized and peptonized. It is a good soil for 
the tubercle bacillus. (Abbott.) 

Blood-serum. This is difficult to prepare. Glass jars with tight 
covers must be carefully sterilized and dried. The animal (at slaughter- 
house) is drawn up by hind legs and the throat cut by one stroke, and 
then the blood caught in the jars. The covers are fastened loosely and 
the jars allowed to stand about fifteen minutes until clotting has begun. 
Then a sterilized rod is passed around the edge of the clot to break all 
adhesions to the sides of the vessel. The covers are then replaced and 
the jars placed in an ice-chest for twenty-four to forty-eight hours. 
Then draw off the serum with a sterilized pipette into tall sterilized 
cylinders, and plug them with cotton. Then place again in ice-chest 
for twenty-four hours to settle. Then draw off either into test-tubes 
(each 8 c.c.) or into flasks. Sterilize by the intermittent method at low 



156 



GENERAL DIAGNOSIS. 



temperatures. If desired the serum can be solidified by exposure to dry 
heat — 78° C. — for two hours. Then the tubes must be sealed with 
rubber caps to prevent drying. 
Loftier' s blood- serum mixture. 

Neutral meat infusion bouillon (see Bouillon) 1 part. 

Grape sugar 1 per cent. 

Blood-serum 3 parts. 

Tube and Plate Cultures. The plate method was introduced by 
Koch for the purpose of isolating individual bacteria from a number of 
them. It may be practised either with gelatin or agar-agar. Three 
tubes previously filled with the culture media are taken and liquefied by 
warming in a water bath, then cooled to the lowest point at w T hich the 
medium remains fluid. One of the tubes is then taken and held in the 
left hand. A sterilized looped platinum wire inserted in a glass handle 
is taken in the other hand, passed through a flame and cooled for 
a few seconds. With this a bit of the material to be examined is taken 
up, the cotton plug is removed from the tube with the free fingers and 
the wire inserted into the medium. By rolling the tube it is thoroughly 
mixed. Then in the same way a second tube is inoculated from the 
first, and a third from the second. Plates have been previously sterilized 
and placed in covered dishes also carefully sterilized. The plates are 
levelled and the contents of tubes poured upon their surface. Then 
they are cooled over ice-water until the medium becomes solid, when 
they are placed in a proper temperature for development. In this way 
the bacteria are sufficiently diluted to form distinct colonies from which 
pure cultures may be obtained. 

A convenient modification of the method is the use of Petri's plates, 
which are flat, round dishes with covers, the bottom of the dish serving 
as the plate. 

Another modification (Esmarctts tubes) is the use of tubes with a 
small quantity (5 c.c.) of the medium. By rolling the tube in the 
fingers the sides are coated with the media, They are then rolled on 
ice, so that the medium solidifies in a thin layer about its walls. 

Smear and Stab Cultures. When the bacteria have been isolated 
by one of these methods, pure smear or stab cultures must be made 
from them. A tube of the proper culture medium is taken in the left 
hand, a bit of a pure colony taken up on a sterilized straight platinum 
needle, the cotton plug removed as above, and the needle thrust straight 
into the medium for a stab culture, or rubbed over a slanting surface of 
media for a smear culture. The plug is immediately inserted and the 
tubes transferred to the incubator. 

When pure cultures have been obtained the species are recognized by 
their mode of growth and behavior in different culture media, the reac- 
tion produced by their growth, and their appearance under the micro- 
scope when stained and unstained. 

When nutrient media are inoculated they must be placed in favorable 
conditions as to temperature. This will be detailed when each micro- 
organism is discussed, as a number of pathogenic bacteria require a 
definite and continuous temperature. 



BACTERIOLOGICAL DIAGNOSIS. 



157 



The primary inoculation will often yield numerous colonies the 
nature of the organism of which must be determined by its morphology 
and biological characteristics. Frequently each colony must be again 
cultivated before complete isolation of the specific bacterium is pro- 
duced. 

Inoculation of Animals. Another method of determining the 
pathogenic character of morbid material, as sputum, pus, or exudation, 
is by inoculating animals with a pure culture. This is done either by 
feeding, by subcutaneous injection, or by injection into the circulation, 
with antiseptic precautions. 

As animals are subject to only a few of the microbic diseases, many 
experiments must often be made before a susceptible animal is found, 
and no conclusion can be reached as to the pathological power of a 
micro-organism until this point has been determined. The clinical 
course of the artificial disease must be observed to fulfil the diagnosis. 

Examination of the animal is made as soon as possible after death. 
The autopsy is made with antiseptic precautions. After the skin is 
removed only sterilized instruments are to be used. The macroscopical 
appearances and mode and progress of infection are noted to aid in the 
diagnosis. When the organs are exposed, material for cultures is first 
obtained by inserting a platinum needle through a small puncture in the 
capsule. Afterward cover-glasses may be prepared for immediate ex- 
amination. Blood is taken from one of the cavities of the heart. After 
the autopsy all remains are to be burned, and all instruments carefully 
sterilized. 

Special Bacteriological Diagnosis. In the preceding section the 
general methods were described by which the micro-organisms were 
searched for. As they are found in different fluids or secretions of 
the body, a discussion of the individual forms the detection of which 
implies an absolute diagnosis, will be considered in different sections 
which treat of the special diseases, or the special fluid in which the 
organism is most frequently found. In the subsequent chapter the 
method of examining pus will be detailed. In that section an account of 
the pyogenic bacteria (the morphology and bacteriological characteristics), 
staphylococcus and streptococcus, will be found. The bacillus of syph- 
ilis, the gonococcus, the fungus of actinomycosis, the bacillus of glanders, 
of anthrax, of leprosy, and of tetanus, will be given. An account of the 
micro-organism of pneumonia and that of tuberculosis will be found in 
the section on sputum, of diphtheria in the section on the pharynx, of 
cholera in the section on intestinal diseases (faeces), and of typhoid fever 
in its appropriate section. In the section on disease of the blood, and 
in the special articles the spirillum of relapsing fever and the protozoa 
of malaria will be discussed. 

The following points must be investigated in order to determine the 
specific nature of the micro-organism which is supposed to be the pro- 
ductive agency of the disease in question, viz. : The form — micrococci, 
bacilli, spirilla, polymorphous ; relation to oxygen — aerobic, facultative 



158 



GENERAL DIAGNOSIS. 



anaerobic, strict anaerobic ; growth in nutrient gelatin — liquefy, do not 
liquefy, do not grow at "room temperature growth on potato ; growth 
on milk — coagulate milk, do not coagulate, etc. ; color of growth — 
chromogenic, non-chromogenic ; spore formation ; movement; pathogenic 
power. 



Note. — For further information concerning technique the student must refer to the work of 
Abbott on the " Principles of Bacteriology," and to Sternberg's " Manual of Bacteriology " for an 
exhaustive account of the technique, and the morphology and bacteriological characteristics of 
all bacteria., pathogenic and non-pathogenic. The text-books of Hueppe, " Die Methoden der Bak- 
terien-Forschung," 1886 ; Baumgarten, " Lehrbuch der pathologischen Mykologie," 1890 ; Fluegge, 
" Die Micro-organismen," 1886 ; and Cornil and Babes, " Les Bacteries," 1890, are profitable for the 
further prosecution of studies. 



CHAPTER V. 



THE EXAMINATION OF EXUDATIONS, TRANSUDATIONS, 
AND CYSTIC FLUIDS. 

Exploratory puncture or aspiration for diagnosis : Instruments. Preparation of 
Instruments. Preparation of skin. Point of puncture. — Exudations (Pus. 
Sero-pus. Gangrenous debris. Blood Serum. Chyle) : Pus. Blood corpuscles. 
Bacteria. Protozoa. Vermes. Crystals. — Chemical examination : Sero-purulent 
exudations. Putrid exudations. Hemorrhagic exudations. Serous exudations. 
Chylous exudations. Pleural effusions. Transudations. — The contents of 
cysts : Hydatid, ovarian, renal, pancreatic. 

Exploratory Puncture or Aspiration for Diagnosis. — The 
presence or absence of fluids in the natural cavities of the body, as the 
pericardium, the pleura, or the abdomen, or in the gall-bladder, must 
often be ascertained by means of puncture or aspiration. The fluid is also 
thus secured to determine its nature. The fluid of tumors or cysts is 
likewise withdrawn to complete a diagnosis by determining its chemical, 
microscopical, or bacteriological character. Certain rules of procedure 
are necessary, and, as they belong in common to the method in whatso- 
ever situation employed, may be considered in this section. 

The Instruments. If it is the desire of the observer to determine the 
presence of fluid, an ordinary grooved needle may be used. If, how- 
ever, fluid is to be obtained for research, a syringe or aspirator must be 
used. An ordinary hypodermatic syringe, or the syringe of Pravaz, 
may be used if the needles are long enough. A special aspirator made 
for diagnosis by instrument-makers is the best. The needles are suffi- 
ciently long, the barrel large enough to hold enough fluid for each 
method of examination. If the diagnosis is to be followed by treatment 
by aspiration, the apparatus of Dieulafoy, or any equally perfect ap- 
paratus, may be used at once. 

Preparation of Instruments. The instruments should be sterilized in 
a steam sterilizer, or boiled. This does not apply to the needles alone, 
but every portion of the instrument should be cleansed, because, for 
instance, the contents of the barrel of the syringe pass through the needle 
when testing it. After sterilization they should be carried to the patient 
in sterilized test-tubes plugged with cotton wool. After boiling, the 
needles should be kept in absolute alcohol, and the syringe in carbolic 
acid solution, 1:20, twenty minutes before operation. 

Preparation of Skin. The sk;in should be first cleansed with soap 
and water, then with alcohol, then with a solution of carbolic acid, 1 : 20, 
or of the bichloride of mercury, 1 : 1000. After thorough cleansing, 
the parts should be kept covered with a towel soaked in bichloride 
solution until the time of operation. At the time of puncture the sur- 



160 



GENERAL DIAGNOSIS. 



face should be made anaesthetic by ethylene chloride, the rhigolene spray, 
or by ice and salt. Care must taken, if the patient is aged or poorly 
nourished, or the skin oedematous, not to freeze the skin too much, on 
account of the danger of local gangrene. 

The Point of Puncture. The points selected for aspiration depend 
upon the cavity the contents of which are explored, or the situation of 
the cyst. 

The Pleura. To determine the nature of fluid within the pleura it is 
best to select a point for aspiration in one of the lower interspaces of 
the chest, because the fluid is more likely to accumulate in this position 
and because complete aspiration can be performed if necessary. The 
sixth or seventh interspace in the anterior axillary line, or the eighth 
or ninth interspaces in the posterior axillary or scapular line may be 
selected. On the right side, the uppermost interspace of the two should 
be chosen on account of the position of the liver. If the contents tend 
to point or break out at any particular spot on the surface of the chest, 
the puncture may be made in this area. 

The Pericardium. For aspiration of the pericardium three points of 
election have been recommended : first, the usual position of the apex 
beat, in the fifth interspace inside of the mid-clavicular line ; second, 
the space between the ensiform cartilage and the left seventh cartilage, 
the point advised by Roberts ; third, Rotch has tapped the fifth right 
interspace a number of times on the cadaver, and thinks that this situa- 
tion is a proper one on the living subject. The writer has aspirated 
the pericardium in several instances inside of the normal position of 
the apex. Care must be taken to insert the needle slowly and with 
the point directed downward and toward the left axilla when this posi- 
tion is selected. 

The Abdomen. It should be remembered at first that no attempts at 
puncturing the abdomen should be made if pus is suspected, unless prepa- 
rations have been made to perform laparotomy at once. Indeed, at 
the hands of modern surgeons this exploratory operation is performed 
with such little detriment to the patient that on the whole it should be 
advocated instead of the method of puncture. There are times, how- 
ever, when the latter must be resorted to. The writer has performed it 
in a number of instances — always refusing to do so in cases in which 
pus was probably present in the peritoneal cavity, or in tumors, or in 
organs connected therewith — without auy danger having ever arisen. 
Explorations of this character are probably more feasible in connection 
with diseases of the liver. It does not appear to be harmful to insert 
needles into that organ, and valuable information is often gained thereby. 

In aspiration of the abdomen, to determine the character of peritoneal 
contents, the median line should be selected for the puncture. The 
bladder must be emptied and a point midway between the umbilicus 
and pubes selected. 

Cysts or tumors with fluid contents should be punctured over the 
point which presents externally, at which place it is evidently in closer 
apposition to the external wall. 

The spleen has been punctured for therapeutic and diagnostic pur- 
poses. If the organ is hard it may be done without danger, but if it is 



EXUDATIONS, TRANSUDATIONS, AND CYSTIC FLUIDS. 161 



enlarged and soft as in infections diseases, such as typhoid fever, it is 
hardly justifiable to puncture it, because of the danger of subsequent 
rupture. Risks attend the puncture of other organs, as the kidney. 
The writer has seen a serious hemorrhage follow such puncture, and of 
course septic inflammation may arise. Exploratory operation is more 
suitable for determining its condition. 

The Examination of Fluids and Discharges. While the fluids 
to be considered are obtained by the above-mentioned method, it some- 
times happens they can be examined when discharged spontaneously, 
as in the case of an empyema. 

The following general methods apply to the examination, from 
whichever of the above-mentioned sources the material is obtained. 
When derived from the natural cavities they are known as exudations 
or transudations. Fluids are also obtained, however, from cysts, but 
these do not require different methods of examination. 

The naked-eye appearances are first noted ; then microscopical exami- 
nation with and without staining is resorted to. Chemical examination 
is also required. Often, as in the case of pus or of serous exudation, 
culture preparations and inoculations must be resorted to. 

The Exudations. They may be composed of pus, sero-pus, gan- 
grenous debris, blood, or pure serum, or chyle. When pus, sero-pus, or 
putrid fluid is withdrawn, it implies absolutely an inflammatory origin. 
Blood and serum may be associated with inflammation, simple or in- 
fectious, but also point to impediments in the general or lymphatic 
circulation. Blood or bloody serum is thought to be of tuberculous or 
cancerous origin. Its absence does not imply the absence of either dis- 
ease. A chylous exudation is usually due to obstruction of the lymph 
channels. 

Pus. Pus ranges in color from gray to greenish-yellow. It is tur- 
bid, of high specific gravity, and alkaline. It varies in consistence. 
When standing after removal it separates into two layers ; the upper 
layer is light yellow and transparent, and the lower opaque. Pus may 
be mixed with blood, and is then reddish-brown. (See Abscess of the 
Liver.) When it has undergone decomposition it is thin, green, or 
brownish-red, of a penetrating odor. 

Microscopical Examination : White Corpuscles. If the specimen is 
fresh the cells exhibit the movements that are common in leucocytes. If 
a solution of iodine and iodide of potassium is added to them they change 
to mahogany color. If the pus is old or the cells are dead, they are 
shrunken and granular. Enormous giant-cells and cells loaded with fat 
are seen in the pus. 

Red Corpuscles. In fresh pus, red corpuscles are also seen along with 
blood pigment or hsematoidin crystals. 

In addition to the corpuscles, fat globules and particles are seen free. 
Epithelium is rarely seen. In the pus from the pleural cavity, if can- 
cer is present, the vacuolated epithelial and endothelial cells sometimes 
seen in cancer may be observed. 

Bacteria. Micro-organisms are always detected with the aid of 

11 



162 



GENERAL DIAGNOSIS. 



staining methods. The micro-organisms are usually the determining 
cause of the suppuration. Suppuration, however, may be caused by 
chemical substances, although this is at least of rare clinical occurrence. 
Of the various fungi found the micrococci and bacilli are the most com- 
mon. Both pathogenic and non-pathogenic varieties are observed. The 
most common are the staphylococcus pyogenes aureus, and streptococcus 
pyogenes. In the pus of empyema the micrococcus lanceolatus, or pneu- 
mococcus, is frequently found, particularly in the empyema that occurs 
secondarily to pneumonia. The bacillus coli communis is found in 
abscesses about the peritoneum and in purulent peritonitis, the amoeba 
dysenterica in abscess of the liver and secondary abscess of the pleura 
and lung. It was found in an abscess of the jaw by Flexner. The 
micrococci are detected by the staining methods. The method of Gram 
is the most satisfactory. 

After a cover-glass has been prepared and placed in Ehrlich-Weigert's 
solution of gentian-violet and aniline water, it is put into a solution of 
iodine and iodide of potassium for two or three minutes. A dull red- 
brown color is produced. It is then rinsed in absolute alcohol for some 
time. The micro-organisms are stained dark blue. The iodide of 
potassium solution is : Iodine, 1 part ; iodide of potassium, 2 parts ; 
distilled water, 300 parts. By this method the various forms of micro- 
organisms just indicated are readily brought out. 

The Pyogenic Bacteria. 1. Staphylococcus Pyogenes 
Aureus. — This micro-organism is found in acute abscesses and boils, 



Fig. 15. 




Pus with staphylococcus. X S00. (Flugge.) 

sometimes also in infectious osteomyelitis and ulcerative endocarditis. 
It enters the tissues through abrasions or the hair follicles. 

Morphology. In cover-glass preparations they appear as small round 
bodies scattered among the pus-cells, rarely within them, single, in pairs 
or clusters. Thev stain readily with the basic aniline dves. (See Plate 
L, Fig. 2, b; and Fig. 15.) 

Biological properties. It is aerobic, facultative anaerobic, grows in 
milk, meat infusions, gelatin, or agar at 18° C. Death-point is 56° to 
58° C. after ten minutes' exposure. Growth. Make plate cultures 
on agar-agar. After twenty -four hours in the incubator the plate will 
be studded with yellow or orange-colored colonies, round, moist, and 
glistening. In a gelatin stab culture, liquefaction occurs in thirty-six 



PLATE II. 



Fig. 1. Fig. 2. Fig. 3. 




Streptococcus— Erysipelas. Streptococcus Septicus. Staphylococcus. 



Fig. 4. Fig. 5. Fig. 6. 




Diphtheria Bacilli. Typhoid Bacilli. Tuberculosis Bacilli. 



EXUDATIONS, TRANSUDATIONS, AND CYSTIC FLUIDS. 163 



to forty-eight hours along the puncture, formiug a funnel. The whole 
mass gradually liquefies. At the bottom of the funnel the microbes col- 
lect as an orange- colored mass. On potato it grows as a brilliant 
orange-colored, somewhat lobulated layer. The growth gives off an 
odor of sour paste. (See Plate II., Fig. 3.) 

2. Staphylococcus Pyogenes Albus. It is also found in acute 
abscesses, but less often than the " aureus," and is less virulent, 

It is morphologically identical with the " aureus," but develops no 
pigment. The surface cultures are milk-white, and the mass at the 
bottom of the liquefying gelatin is white. 

3. Staphylococcus Epidermidis Albus closely simulates the 
staphylococcus pyogenes albus. It is the most common micro-organism 
on the surface of the body, and is often present in parts of the epidermis 
too deep for disinfection save by heat. It is supposed to be the usual 
cause of " stitch abscess." 

4. Streptococcus Pyogenes. It is found in acute abscesses, ery- 
sipelas, otitis media, puerperal metritis, ulcerative endocarditis, pseudo- 
diphtheria, scarlatinal angina, and most purulent inflammations of a 
phlegmonous character. 

Fig. 16. 




Streptococcus pyogenes in pus. X 800. (Flugge.) 



Morphology. Cover-glass preparations show spherical cocci of vary- 
ing sizes, which form chains of four to twenty elements, the chains 
often forming tangled masses. It is stained by the basic anilines or by 
Gram's method. (See Plate I., Fig. 2, B; and Fig. 16.) 

Biological properties. Grows in most media at temperature of 16° to 
37° C. (best 30° to 37°), but not on potato. It is a facultative anaero- 
bic, and does not liquefy gelatin. On plates it forms a flat transparent 
disc of about one-half millimetre diameter. In stab cultures it grows all 
along the puncture and forms a white opaque granular column. The 
death -point is 52° to 54°, ten minutes exposure. (See Plate II., Fig. 1, 
and Fig. 2.) 

Inoculated, it causes erysipelatous or phlegmonous inflammation. 

5. The Tubercle Bacillus. This is seen at times in pus removed 
from phthisical cavities, and the pus of abscesses, particularly about 
glands. It may be detected by methods of staining adopted in the 
examination of the sputum. Pns may be of tubercular origin, and 
the micro-organisms not detected by the usual methods. Its absence, 
therefore, does not imply the absence of tubercle. Culture methods and 
inoculation should be resorted to. 



164 



GENERAL DIAGNOSIS. 



6. Bacillus of Syphilis. The pus under these circumstances is 
usually derived from ulcers or inflammations, or from secretions about 
the vulva or prepuce. 

Lustgarten's method is as follows : After immersion for twenty-four 
hours at the ordinary temperature in the gentian-violet fluid of Ehrlich- 
Weigert, the cover-glass preparation is removed and washed for a few 
minutes w T ith absolute alcohol. It is then placed for ten seconds in a 
1 per cent, or 2 per cent, solution of permanganate of potash ; a watery 
solution of pure sulphurous acid is then poured over it, after which it 
is washed in water. If the preparation still shows color it must be 
re- immersed for a few seconds in the potash solution and then in the 
sulphurous acid, and again washed with water. 

7. Actinomyces. Israel and Pomfret have given us the greatest 
amount of information in regard to this parasite. It was discovered by 



Fig. 17. 

O 




Actinomyces. 



Bollinger. It is usually associated with chronic inflammation and the 
production of pus. The pus is peculiar. It is thin and viscid. Small 
nodules of a gray or yellow color the size of a poppy seed by the naked 
eye can be seen when it is spread out on a glass. With a low power 
these particles are aggregations of spherules, which with a higher power 
are seen to be arranged in masses radiating from a common centre. Each 
separate spherule is pear-shaped. They have high refractive power. 
In the centre of the masses a network of fibres is seen. If the mass is 
broken up numerous club-shaped forms in the periphery are seen, while 
at the centre a sort of detritus alone is observed. The micro-organism 
belongs to the class of fission fungi, and the club-shaped bodies are the 
degenerated forms. (See Fig. 17.) 

Gram's method of staining brings out the threads of the network 
most distinctly. The centre is made up of a network of minute spher- 
ical organisms, with converging constituent threads. The whole is 
surrounded by a delicate envelope. The pear-shaped bodies may be 
defined by Weigert's process. Make a solution of 20 c.c. of absolute 
alcohol, 5 c.c. of concentrated acetic acid, 40 c.c. of distilled water, and a 
sufficient French extract of litmus to color it ruby red after repeated 



EXUDATION'S, TRANSUDATIONS, AND CYSTIC FLUIDS. 165 



filtering. Id this solution the cover-glass preparations are allowed to 
remain for an hour, and then rinsed with alcohol rapidly and placed in 
a 2 per cent, gentian-violet solution for three minutes. The fluid 
should be boiled before use, and filtered after cooling. The fungous 
threads are stained a ruby-red, while the central mass of actinomyces is 
colorless. 

Simple microscopical examination is usually sufficient to determine 
the nature of the fungus. The recognition is more positive if the pecu- 
liar character of the pus is borne in mind in which the nodules are seen, 
and the club-shaped forms. Pure cultures have been obtained resem- 
bling the cultivation of the tubercle bacillus. 

8. The Bacillus of Glanders. The pus is usually discharged 
from the nasal passages. It is detected in dried preparations (see Blood). 
Loffler's method also enables them to be detected readily. An aniline- 
water gentian-violet fluid is added to its own bulk of solution of potash 
1 : 10,000. The cover-glass is immersed for five minutes in the fluid. 
It is then removed and placed in a 1 per cent, solution of acetic acid for 
one minute. The acetic acid should be tinged slightly yellow with 
tropseolin. The preparation is then bleached by washing in a solution 
containing two drops of concentrated sulphuric acid and one of a 5 per 
cent solution of oxalic acid in 10 c.c. of water. The bacillus is also 
obtained from the pus of an abscess. Its characters are determined by 
the above methods. It may be cultivated and inoculated in obscure cases. 
Growth. When cultivated, the wet cultivation crop has the appearance 
of a grayish- white drop. On a potato, at a temperature of 35° C. 
it grows a thin greasy coating of a brown color. On blood-serum 
at a low temperature, small scattered transparent drops the color of the 
serum are seen. It also grows upon glycerin agar-agar and in nutrient 
milk peptone. Field mice and guinea-pigs are readily infected by in- 
oculation with pure cultures. 

9. Bacillus of Anthrax. The pus is derived from the carbuncle 
in this disease (see Blood). Cultivations may be resorted to, but it can 
readily be recognized by usual methods of staining. (See Plate I., Fig. 
2, a.) Growth. In the nutrient gelatin medium the bacillus develops in 
from twenty-four to thirty-six hours. With the glass the scarcely visible 
minute points are seen to be made up of colonies of an irregular undu- 
lating outline, dark in color. After forty-eight hours their shape is more 
characteristic, and then the cultivation begins to liquefy, stretching 
over the surface of the plate in wavy stripes. On a sterilized border 
it forms a whitish gray, slimy patch of uneven surface, scarcely ex- 
tending over the site of inoculation. On blood-serum the superficial 
coating of white color is formed. On nutrient gelatin delicately inter- 
woven white threads followed by liquefaction of the gelatin are seen. 
In drop cultivations in nutrient broths, long shreds develop at regular 
intervals. Inoculation of the bacillus causes symptoms of splenic fever 
and the organism is found in the blood. 

10. The Bacillus of Leprosy. The micro-organism is found in 
the nodes, on the skin and mucous membrane. When they break down, 
abundant thin pus is poured out. The bacilli in large numbers are 
found. They are in the form of rods 4 to 6 ^, and 1 n in breadth, and 



166 



GENERAL DIAGNOSIS. 



resemble the bacillus of tubercle. They stain in alkaline fluids, but do 
not bleach after subsequent exposure to acids. They stain readily (see 
Sputum). A dry cover-glass preparation must be made and the pus 
stained with tbe Ziehl-Xeelsen fluid (carbol-fuchsin) and then decolor- 
ized in acid and alcohol. It is said that the micro-organism has been 
inoculated, and also cultivated, although thus far not with diagnostic 
value. 

11. The Bacillus of Tetanus. The bacillus is seen as a delicate, 
slender rod, with a terminal spore. It stains with aniline dyes and 
Gram's fluid. Cultivations may be made with the pus. The first 
cultivations usually contain different fungi. After heating to 80 C. in 
water bath for half an hour to an hour for several days, gelatin plates, 
to which 2 per cent, of grape sugar has been added, are inoculated. 
The plates should be kept, according to Kitasato, in hydrogen atmos- 
phere at 20° to 25° C. If the inoculation is made under the surface of 
the gelatin, growth begins near the surface. Faint radiating striae, or 
thorn-like processes are seen. The development is rapid in agar-agar. 
After exposure to a temperature of 37° C, after thirty hours the spores 
make their appearance. On gelatin the colonies are dense at the centre 
with a more delicate periphery. The preparation becomes fluid and 
gas is evolved. It is strictly anaerobic. 

12. Bacillus of Influenza. (See Sputum.) 

13. Micrococcus Lanceolatus. Pneumococci. In the pus of 
empyema, whether from the pleural cavity, or after it has burrowed 
from other situations, the pneumococcus has been frequently found. It 
is easily detected by the usual staining methods (for which see Sputum). 

14. Bacillus Coli Communis. The bacillus coli communis is 
found in suppurations about the abdominal cavity (see Faeces). 

15. The Gonococcus. It is constantly present in virulent gonor- 
rhoeal pus ; usually within the pus cell or attached to the surface of epi- 
thelial cells. Morphology. Micrococci, usually joined in pairs or fours, 
flattened and separated, when stained, by an unstained intercellular 
space. Stains easily with anilines — not by Gram's method. 

Xo other cocci are of the same shape, and at the same time within the 
cells, except one which, however, stains bv Gram's method. (See Plate 
I., Fig. 3, 6). 

Growth, Does not grow readily on media, but can be cultivated on 
blood-serum ; 30°-40° C. is best, and a moist atmosphere is needed. 
Growth is slow and often fails. Forms a thin, scarcely visible layer, 
with smooth, shining surface, grayish -yellow by reflected light — is 
aerobic. 

Inoculation into the human urethra produces a typical attack of 
gonorrhoea. 

Protozoa in the Pus. Cercomonads have been observed in the 
pus of an empyema, probably from the lungs. Flexner has found the 
amoeba dysenterica in the pus of an abscess of the jaw. It is found in 
abscess of the liver and secondary abscess of the lung (see Sputum and 
Faeces). 



EXUDATIONS, TRANSUDATIONS, AND CYSTIC FLUIDS. ,167 



Vermes. Filaria have been found in abscess of the liver. Id the 
suppuration of hydatids the pus contains membrane and hooklets. 

Crystals. Crystals of cholesterin are found in the pus from cold 
abscesses, suppurating ovarian cysts, and foetid discharges. They are 
similar to the crystals described under Sputum. 

Hcematoidin crystals indicate a previous hemorrhage ; they are most 
frequent in suppurating hydatid cysts. (See Fig. 18.) Fatty needles 
are found in old pus and gangrenous exudates. (See Fig. 19.) Triple 
phosphates are frequently seen in pus and are of the same appearance as 
the phosphates in the urine. The carbonates and phosphates are seen 
in foetid pus. 

Fig. 18. Fig. 19. 




Pus from putrid empyema. (Eye-piece 
Rhombic crystals of Heernin. (Charles) III., obj. 8, A. Reichert). Shrunken leuco- 

cytes. Fat crystals. (Von Jaksch.) 



Chemical Examination of the Pus. This does not yield infor- 
mation that is of diagnostic value. 

Serum albumin, globulin, and peptone are detected by methods em- 
ployed in the examination of the urine. Fresh pus contains sugar. 
After being boiled with an equal weight of sulphate of soda and filtered 
the filtrate is examined by the reagents used in examination of the urine. 
In addition to the above, pus contains bile pigments and biliary acids, 
cholesterin and salts of sodium and the fatty acids in jaundice. Von 
Jaksch has found acetone in pleural exudations. 

Sero-purulent Exudations. They resemble purulent dis- 
charges chemically and morphologically. They point to antecedent 
inflammation. 

Putrid Exudations. The exudations are brown or brownish- 
green in color. The odor is penetrating and offensive. They are 
usually alkaline in reaction. On microscopical examination, old leuco- 
cytes and crystals of fat, cholesterin, and hsematoidin are seen ; fission 
fungi of various forms are seen. (See Figs. 18 and 19.) 

Hemorrhagic Exudations. Hemorrhagic exudations contain 
red blood-corpuscles and haemoglobin in large amount. Fatty endo- 
thelial cells are found. Quincke states that when the glycogen reaction 
is shown, if the fluid is from the pleura, carcinoma is probably present. 
A positive diagnosis depends upon the discovery of the epithelial cells, 
w T hich are seen in cases of caucer. Hemorrhagic exudations in the 
pleura are due most frequently to cancer, to tubercle, or to scurvy. 



168 



GENERAL DIAGNOSIS. 



To determine its exact nature (as to tubercle), inoculation and cultures 
are sometimes necessary. (See Fig. 15 ) 

Serous Exudations. The fluid is clear and light yellow or straw- 
colored. On standing, a white fibrinous clot is deposited. On micro- 
scopical examination, red blood-corpuscles, leucocytes, fatty globules 
and endothelial cells are found. They may be bunched in groups or 
scattered about. The micro-organisms, if present, are detected with 
difficulty. If ulcerating tuberculosis of the pleura is present, the bacil- 
lus may be found. Tuberculous pleurisy may exist without ulceration, 
and hence the fluid is clear of the bacillus. Cholesterin crystals are 
found in old serum. On chemical examination the fluid contains serum 
albumin and globulin ; peptone is absent ; sugar in small amounts, and 
acetone in pleural exudations. 

The specific gravity of the fluid is above 1018. 

Chylous Exudation. Sometimes in peritoneal exudation, particu- 
larly if the patient has been upon a milk diet, the fluid contains fatty 
matter which gives it a milky appearance. The same character of fluid 
is seen in obstruction of the thoracic duct. True chyle is found in 
fluids of low specific gravity. Such an effusion is rich in fat and is due 
to leakage of lymphatics into the peritoneal cavity. It is known as 
a chylous effusion. Chyliform effusion is a term applied to the effusion 
first mentioned in this section. The fluid has the property of chyle. 

Special Effusions. Effusion in the Pleura. It is of the greatest 
importance to distinguish the various forms. Bacteriological examina- 
tion is often necessary. In purulent exudation, if micro-organisms are 
absent (staphylococcus and streptococcus) it is probably tuberculous ; 
sero-fibrinous exudations are usually free from fungi. TThen the 
micrococcus lanceolatus is found it is of favorable prognostic omen. 

To distinguish the effusion of inflammation from that of transudation 
(obstruction) the specific gravity is of service. In the inflammatory 
effusions the specific gravity is high ; the latter also contain a large 
amount of fibrin. 

Transudations. This class of fluids is serous, bloody, or chylous. 
The specific gravity is lower than in inflammatory effusion. They are 
light in color ; usually alkaline. On microscopical examination but 
little is found. In pleuritic effusions there may be considerable endo- 
thelium which, if with blood, may be due to carcinoma. Serum contains 
albumin and sugar, the former in great excess. Peptone is always 
absent. The fluid coagulates with difficulty on boiling. 

Contents of Cysts. In the aspiration of the abdomen, and some- 
times of the pleura, cysts are evacuated, the nature of which is often 
determined by an examination of the fluid. It is within the province 
of this work to discuss hydatid cysts, pancreatic cysts, and the cystic 
kidney. As tumors of the ovary so frequently resemble tumors in other 
situations, it is well to discuss in this section the nature of the fluid 
withdrawn. 

Hydatid Cyst. The fluid of hydatid cyst is clear, alkaline, and of 
specific gravity of 1010. It contains chloride of sodium in excess, 



EXUDATIONS, TRANSUDATIONS, AND CYSTIC FLUIDS. 169 

grape sugar in small amount, and very little, if auy, albumin. On 
microscopical examination hooklets, as in the sputum from the same 
cause, are found, and portions of membrane. The membrane is recog- 
nized by its peculiar transverse striation and the granular appearance 
of its inner surface. The heads or scolices are sometimes found. 
Two circles of hooklets and four disks on the anterior aspect cross the 
head, which is separated from the hinder part by an annular constric- 
tion (see Sputum and Faeces). If suppuration has taken place the orig- 
inal nature of the cyst cannot be made out unless hooklets are found. 
On standing in a conical glass vessel the bodies may be found in the 
sediment. 

Ovarian Cysts. The fluid from an ovarian cyst is of high specific 
gravity, 1026, of alkaline reaction, contains but a small amount of albu- 



Fig. 20. 




Contents of an ovarian cyst. (Eye-piece III. obj. 8, A. Reichert.) a, squamous epithelial cells; 
.'>, ciliated epithelial cells ; c, columnar epithelial cells ; d, various forms of epithelial cells ; e, fatty 
squamous epithelial cells ; /, colloid bodies ; g, cholesterin crystals. (Von Jaksch.) 

min, and does not coagulate. On microscopical examination various 
forms of epithelial cells are seen, colloid bodies, and cholesterin crystals. 
If hemorrhage has taken place in the cyst the color of the fluid is cor- 
respondingly changed, and in addition to squamous, columnar and 
ciliated epithelium, some in the stage of fatty degeneration, and red and 
white blood-corpuscles are seen. In colloid cysts the usual concretions 
are found. (See Fig. 20.) 

In dermoid cysts, in addition to the above, squamous epithelium, 
hairs, and fatty, hsematoidin, and cholesterin crystals are detected. 
Ovarian fluid contains albumin and methsemoglobin, or paralbumin. 
The latter is detected by mixing a portion with three times its bulk of 
alcohol. It is then allowed to stand for twenty-four hours, when it is 
filtered. The precipitate is removed and suspended in water. After 
filtering, the filtrate is seen to be opalescent and is tested as follows : 



170 



GENERAL DIAGNOSIS. 



1. On boiling no precipitate is formed, but the fluid becomes turbid. 

2. There is no change with acetic acid. 

3. The fluid becomes thick aud of a yellowish tint when treated with 
acetic acid aud ferrocyanide of potassium. 

4. There is change to a violet color when treated w T ith concentrated 
sulphuric and acetic acids. 

Some observers differ from the above statement in their description of 
the fluid of ovarian cysts ; all agree as to the large number of cell ele- 
ments. At one time it was thought that the fluid contained a special cell, 
but this is now disregarded. In rare cases the specific gravity may be 
low r er than that of the fluid of ordinary ascites. A fluid of low specific 
gravity with a small amount of albumin is said to be characteristic of a 
cyst of the broad ligament. 

Cystic Kidney. The fluid of the cystic kidney can be recognized by 
the properties it derives from the renal secretion. Urea and uric acid 
in large amounts point to its true source. Renal epithelium is of the 
greatest diagnostic value (see Urine). If epithelium from the urinary 
tubules can be detected after the fluid has settled the diagnosis is absolute 
(see Hydronephrosis). It must not be forgotten that both urea and uric 
acid may be found in other cysts, as of the ovary, if they communicate 
with the urinary tract. 

Pancreatic Cysts. Recently the fluid from cysts of the pancreas has 
been examined and proved of diagnostic value in determining the 
nature of the abdominal tumor. The fluid is of a specific gravity of 
1012, but may be as high as 1028. It contains cholesterin crystals in 
abundance, and blood or pigment. Serum albumin is present, but met- 
albnmin is not found. The diastatic ferment is present. This may be 
met w T ith in the faeces and in the secretions of the mouth. If on 
examination for sugar the latter is found to be a maltose its presence is 
of diagnostic significance. 

The most pronounced property of the pancreatic fluid, and that by 
which we are enabled to distinguish it from other fluids, is the power of 
digesting albumin without the presence of an acid. 

Boas (Deutsche med. Wochenschr., 1890, Bd. xvi., p. 1095) developed 
the method of examination. The fluid is to be added to milk ; after the 
casein is precipated the biuret test is applied. Heat the substance with 
caustic potash and add drop by drop a 10 per cent, solution of sulphate 
of copper. If digested albumin is present the fluid assumes a reddish- 
violet color. No other cystic fluid can dissolve albumin in the alkaline 
solution. The fluid also emulsifies fats. In large cysts, however, 
particularly of long standing, the physiological properties of the 
pancreatic juice are sometimes wanting. In the case referred to by 
Boas and reported by Karewski, the old age of the cyst modified the 
character of the fluid and hence rendered its nature doubtful. More- 
over, in the exploratory puncture the stomach was penetrated. For 
two reasons the author advises against exploratory puncture. First, the 
age of the cyst is not known, hence an analysis would be misleading. 
Second, the danger of puncturing other organs is too great. Explora- 
tory laparotomy is preferable. 



CHAPTER VI. 



THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 

Knowledge of symptoms of morbid processes essential ; they control conclusions drawn 
from data. — Morbid processes are few. I. Alterations in blood and circulation : 
Anaemia and plethora — Hypersemia, active and passive— (Edeina and dropsy 
— Thrombosis and embolism — Hemorrhage — Blood-pressure. II. Disturbances 
of nutrition : Inflammation — Gangrene and necrosis — Fever — Atrophy and 
hypertrophy. Degenerations : Albuminous — Fatty — Colloid — Mucous — Pigmen- 
tary — Calcareous — Amyloid — Fibroid. III. Anomalies of growth : Tumors — 
Cysts — Cancer. 

Notwithstanding our having secured the data obtained by inquiry 
and data obtained by observation based upon which the diagnosis if 
possible is made, the conclusion arrived at is often not final, and perhaps 
from the nature of the case cannot be. We are prompted, therefore, to 
view the case from a different standpoint, to utilize our knowledge as to 
the phenomena of morbid processes, and for the purpose of compari- 
son to review the features of those that are apparently of the nature 
of the process under consideration. Thus, for instance, in an obscure 
case of fever, the objective and subjective phenomena have been fully 
inquired into : we are unable to decide whether the disease under con- 
sideration is a septic process with obscure lesions, a form of miliary tuber- 
culosis, or of malignant endocarditis. The symptoms of each are con- 
sidered, our knowledge of such symptoms depending upon our knowledge 
of the phenomena of the respective morbid process. Moreover, after 
a diagnosis is made, a review of the symptomatology of morbid pro- 
cesses answers as a control experiment to the conclusions that have been 
attained. We should also, after a diagnosis is made, compare the symp- 
toms of the process in the individual case with the symptoms which 
we know to be of common occurrence in the disease thought to be 
present. 

It is necessary, therefore, that the student should fully know the 
symptoms of morbid processes. Each process is characterized by 
phenomena common to it, and by which it is recognized. The symp- 
toms are modified by the function and anatomical structure of the 
organ in which the process takes place. Thus the symptoms of in- 
flammation of the mucous membranes of the bronchial tubes and of the 
stomach are the same except that from difference in function in the one 
we have cough ; in the other, vomiting. Very frequently the symptoms 
differ because of physical and hence mechanical alterations. Thus an 
inflammation of the pericardium and of the pleura are allied, but in the 
former pressure symptoms ensue that are infinitely different, because of 
the anatomical relations, from the pressure symptoms of the latter. 



172 



GENERAL DIAGNOSIS. 



The morbid processes are not many. They include : I. Alterations 
in the blood and circulation ; II. Disturbances of nutrition ; III. 
Anomalies of growth. 

I. Alterations in the Blood and Circulation. The composition 
and distribution of the blood affects all the tissues for weal or woe. 
The quantity of the blood alone will be referred to ; changes in quality 
will be considered under diseases of the blood. Practically the symp- 
toms produced when the quality is affected are those of anaemia plus 
the symptoms (physical and functional) of the primarily diseased organ 
— as the spleen in leucocythaemia. The quantity may be increased or 
diminished. 

1. Increased Quantity of Blood, or Plethora. Formerly 
this was considered an entity, and the symptoms of flushed face, hot and 
full head, throbbing pain, throbbing temporals, a full, strong pulse, 
sluggish intellect were thought to indicate an excess of the general bulk 
of the blood. True plethora is rarely permanent. If transitory, the 
veins and not the arteries are overfilled. The symptoms are not due to 
general plethora but to excess of blood-pressure or to special determina- 
tions of blood to superficial vessels, determined by a nervous mechanism. 
Increase in one of the cellular elements of the blood, the leucocytes, is 
not a plethoric condition. 

2. Diminished Quantity of Blood, or Anaemia. Anaemia 
embraces diminution of the bulk of the blood, or any one of its mor- 
phological constituents. 

The term might be used for loss of water of the blood, as in cholera 
Asiatica (see Infectious Diseases), or in serous purging. The symptoms 
are those included in the term collapse. 

Oligemia or spanaemia are terms that may be used to define the 
general thinness or poorness — atrophy of the blood. Clinically, anaemia 
is divided into simple anaemia, general poverty of blood; pernicious 
or idiopathic anaemia, reduction in the number of red cells; chlorosis, 
reduction in the quautity of haemoglobin ; leucocythaemia, relative loss 
of red, increase of white corpuscles. (See Diseases of the Blood.) 

3. Local Disturbance of the Circulation. Hyperemia, or 
Congestion. The process may be acute or chronic. It is usually local, 
although it may be general. When the latter, many organs may be 
simultaneously involved, due to a common cause. 

Symptoms. The acute or active form of hyperaemia is always local and 
arterial. There is increased blood in the part. If the skin is the seat, 
there is redness and increased heat, and throbbing or pulsation may be 
seen. The parts are swollen. The excitability of the nerves is increased, 
with local symptoms of warmth, fulness, or itching. The morbid blush- 
ing, or flushing, that occurs at the menopause or reflexly from internal 
disorder, is a hyperaemia, while in erythema of the skin it is seen in 
most marked degree. 

Causes. Arterial hyperaemia is caused by (1) neuro-paralysis of the 
inhibitory or vaso-constrictor fibres, of the cervical, sympathetic, 
splanchnic, and other sympathetic and some mixed nerves, as the sciatic; 
(2), neuro-tonic stimulation of the actively dilating or vasodilator nerves, 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 173 



as the chorda tympani. Under both circumstances there is relaxation 
of the arterial walls. This may also occur directly through the vaso- 
motor system, induced by heat, electricity, or chemical irritants, or from 
paralysis of muscular fibres, after spasmodic contraction due to cold, as 
frost-bite. 

Causes and Symptoms of Neuroparalytic Hyperemia. 
A tumor pressing upon the cervical sympathetic uerve, abscess which 
destroys it, and wounds of it, produce hyperemia of the side of the 
face, rise of temperature, and contraction of the pupil. Later on, the 
vascular conditions are reversed. Lesion of the fifth nerve, or a branch, 
causes hyperemia of the iris, the conjunctiva, the cheek, the gums, and 
other structures supplied by it, with associate loss of sensation followed 
by atrophy. The latter conditions have nothing to do with the vascular 
paralysis. 

Neuro-tonic Hyperemia. After wounds of the brachial plexus, 
hyperemia of the fingers is seen. (See Fingers.) The local tem- 
perature is elevated, and there is neuralgic pain. Local hyperemia 
with hyperesthesia, known as erythromelalgia, belongs to the same 
class, due to affections of the nerve trunks, or the peripheral nerve- 
endings. Reflex hyperemia must be remembered. 

Chronic or Venous Hyperemia (passive congestion). The 
blood accumulates in the veins aud, by backward pressure, in the capil- 
laries. The venous capillaries are overdistended and, compared with 
the arterial, much enlarged. They contain venous blood. 

Any congested part, as the exterior, is bluish or purple in tint, often 
swollen (clubbed fingers), cooler than normal, with lessened sensation and 
without pulsation. (See Cyanosis.) The dependent parts are first 
affected, as the legs, or the lungs. In fevers the weak heart and the 
recumbent posture predispose to the latter. 

Causes. Obstructive heart and lung disease cause general venous 
congestion. Local venous congestion is caused by tumors, the pregnant 
uterus, collections of feces pressing upon the veins. It is also caused 
by inflammation of the veins, as thrombosis. 

Local Anjemia. This may be due to arterial thrombosis or embol- 
ism ; arterial obstruction through endarteritis ; arterial spasm. Ray- 
naud's disease is a form of arterial spasm. The grave effects of arterial 
obstruction are seen in cerebral anemia from endarteritis, or myo- 
carditis from obstruction of the coronary arteries. 

(Edema and Dropsy. The changes of the circulation which pro- 
duce these conditions have been referred to in the third chapter of this 
book. The symptoms and signs of the condition are also noted in the 
same section. 

Thrombosis and Embolism. The student should be familiar with 
the symptoms of these conditions and, fully as important, with the causes 
that give rise to them. Thrombi may form in the heart, the arteries, 
or the veins. Emboli may form in either vascular channel, but are 
found in the vessels only. 

Thrombosis. The symptoms of thrombosis are : 1. Mechanical. The 
channel is obstructed; hyperemia, engorgement, oedema, and cyanosis 
arise. Its most typical form is seen in femoral thrombosis, with swelling 



174 



GENERAL DIAGNOSIS. 



cyanosis, and oedema of the leg. When an artery is obstructed, the 
symptoms are like those of occlusion under other circumstances (see Em- 
bolism) ; when a vein, the mechanical symptoms vary in accordance with 
the particular vein affected. Thus in thrombosis of the coronary vein, the 
heart's action is interfered with ; of the portal vein, jaundice (not be- 
cause of the obstruction), oedema (ascites), congestion (gastric and intes- 
tinal) occur, as in obstruction in any vein ; in the cerebral veins, disturb- 
ance of the function of the brain ; in the pulmonary veins, dyspnoea. 

2. Inflammatory or septic. If it should happen that the thrombosis 
developed secondarily to an inflammation of septic origin, as in the ex- 
tension of an inflammation into the radicles of the portal vein from an 
abscess about the rectum or vermiform appendix, it would be infected 
with micro-organisms. An infectious inflammation with chills, fever, 
sweats, and other phenomena of a septic character would result. 3. Em- 
bolic. From the thrombus, emboli are washed off; hence, embolic 
symptoms arise in the course of thrombosis. 

While thrombosis is usually easily recognized, it is necessary to call 
attention to the very great importance of going a step beyond, to seek for 
the cause of the thrombosis. Knowing the causes of thrombosis, often 
a thrombus otherwise not suspected can be adjudged as the cause of the 
symptoms. The causes are not many. 1 . Stagnation or stoppage of blood. 
It is seen chiefly in the veins and the heart. External pressure upon the 
veins, as upon the pelvic veins in pregnancy or abdominal tumor, 
upon the hemorrhoidal veins, upon the portal veins by tumor, upon 
the pulmonary veins by mediastinal tumor. It must be remembered 
that some change takes place in the internal coat of the vein also, but 
that the pressure is primary. Then we have weakness of the heart as 
a cause of stagnation. Feeble contractions lead to the formation of 
cardiac thrombi. 2. Thrombosis from changes in the walls. The 
change is usually inflammatory and often proceeds from wounds. If the 
wound was septic, the inflammation will be septic. In the heart, endo- 
carditis ; in the aorta, atheroma leads to the development of thrombi. 

3. Thrombosis from the entrance of a foreign substance into the vessels. 
A carcinoma or other new growth may extend into the veins. Micro- 
organisms penetrate the vein and cause inflammation and thrombosis, 
or infect a previously existing thrombus. The clot is then broken and 
distributed throughout the system, causing pyaemia. 4. Thrombi are 
produced by extension. A clot enlarges by coagulating the blood next 
to it. A large venous distribution may become blocked, as first the 
uterine veins, then the internal iliac, then the external iliac, and from 
thence the femoral — causing the affection which frequently occurs iu the 
puerperal form, phlegmasia alba dolens. 

Embolism. An embolus is a substance which plugs a vessel. It may 
be a fragment of blood-clot (thrombus), vegetations from valves of the 
heart, parasites, new growths which entered the veins, fat, or air. 
If obstruction of the vessel alone is produced the embolus is said to be 
simple. If obstruction and a new process, as inflammation, is set up it 
is specific. Fragments from a thrombus in the systemic veins may 
produce an embolus which blocks the pulmonary artery ; a clot or por- 
tion of valve leaflet from the left heart will block a systemic artery, as 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 



175 



a cerebral vessel or the femoral vessel ; a clot in the portal vein will 
obstruct branches in the liver. 

The symptoms are sudden in occurrence and depend upon the artery 
that is obstructed. The cutting off of blood supply causes, beyond 
the point of obstruction, cessation of function. In pulmonary venous 
embolism the dyspnoea is pronounced, the heart's action rapid and 
irregular, and many cases are called cases of " heart failure." In 
the middle cerebral artery the embolus causes aphasia and mono- or 
hemiplegia. In embolus of the pulmonary artery cough and hemorrhage 
with dyspnoea occur suddenly. The patient has, in this instance, no 
doubt, mitral regurgitation and dilated right heart. 

The result of blocking of an artery varies in many cases. If the main 
artery of the leg is blocked, anastomosis may be set up to compensate 
for the obstructed channel. If this is not secured gangrene ensues. If 
an artery to an internal organ is blocked anastomosis may occur, if the 
artery is not terminal. If the artery is terminal there results rapid necrosis 
or softening, as in the brain ; gradual wasting, as of a kidney, or en- 
gorgement of the arterial area and diffuse hemorrhage. The latter is 
known as a hemorrhagic infarct. This may occur in the lungs (pul- 
monary artery), spleen, kidneys, retina, and, rarely, the intestinal canal. 
The symptoms of hemorrhagic infarct are swelling and hemorrhage. 
In the lungs, there are physical signs of consolidation, with haemo- 
ptysis, cough, and dyspnoea ; in the kidneys, pain and hsematuria ; in 
the spleen, pain and at times enlargement ; in the retina, blindness with 
ophthalmoscopic changes ; in the intestine, pain and hemorrhage with 
sloughing of mucous membrane. Infective emboli cause abscesses. 
Capillary embolism is seen in the skin and mucous membranes in many 
infective diseases, notably ulcerative endocarditis. Fat embolism occurs 
in the pulmonary capillaries, and is due to fat globules which sometimes 
enter the circulation in pregnant women, in patients with bone disease, 
as osteomyelitis or fractures. The symptoms are those of intense 
dyspnoea. It may cause sudden death. 

Air Embolism. Air may enter wounds of the veins of the neck. It 
accumulates in the heart, and as the ventricle cannot contract on it the 
blood is not propelled. Death takes place with the symptoms of heart 
clot, the heart being in asystole. 

Hemorrhage. Hemorrhage may be arterial, venous, or capillary. 
It may occur because the blood soaks through the walls, by diapedesis ; or 
it may occur from rupture, or rhexis. The former takes place in venous 
engorgement, stasis, or inflammation. It is the small passive hemorrhage 
of congestion, as in pulmonary congestion from heart disease ; it is 
venous or capillary ; the blood is dark. Hemorrhage by rupture is 
arterial, venous, or capillary. If the artery, it has been torn by vio- 
lence, destroyed by ulceration or suppuration, or it is the seat of 
endarterial change. Veins are also diseased or the walls destroyed 
before rupture takes place. Rupture of capillaries occurs from violence 
or great internal pressure. In death from suffocation the capillaries 
are the seat of hemorrhage because of the increased venous pressure. 
It occurs in typhus, hemorrhagic smallpox, and scarlatina. The state 
of the blood sometimes is the cause of hemorrhage, as in scurvy, 



176 



GENERAL DIAGNOSIS. 



purpura, and other conditions. Haemophilia is a peculiar hereditary 
affection due to the state of the blood possibly — more likely to the 
condition of the bloodvessels. 

The special forms of hemorrhage and their symptoms, aetiology, and 
diagnosis will be considered in the sections to which the name in the 
following list points : 

Bleeding from the nose — epistaxis. 

Vomiting of blood — hcematemesis. 

Bleeding from the lungs — hcemoptysis. 

Blood passed with the urine — hcematuria. 

Blood passed from the uterus — menorrhagia or metrorrhagia. 
There is also intestinal hemorrhage — melcena. 

Hemorrhages underneath the skin are known as petechias if small, 
and ecchymoses or suffusions if large. 

Hemorrhage into internal organs receives its name from the organ 
affected and is known as a parenchymatous hemorrhage. Apoplexy 
is applied to hemorrhage into the substances of organs, particu- 
larly if it occurs suddenly and is localized — -as pulmonary apoplexy, 
cerebral apoplexy, spinal apoplexy. Long usage has associated the 
term with hemorrhage into the brain, so that it is applied to that form 
only by most writers. Hematoma, or blood tumor, is a collection of 
blood that has coagulated in a cavity, organ, or tissue. (See Ear.) 

The symptoms of hemorrhage vary in degree in accordance with the 
amount of blood which escapes from the vessel, and depend upon 
whether the hemorrhage is external or internal. By an external hem- 
orrhage we mean one which is accompanied by a discharge of blood 
visible to the bystander. An internal or concealed hemorrhage is not 
apparent by any outward sign of blood. 

The symptoms by which external hemorrhage is recognized need not be 
detailed. The show of blood in situations or at times other than normal 
is sufficient. It must be remembered that arterial blood is bright red, 
venous blood dark. It must also be remembered that the character of 
the blood from internal organs is modified by the secretion of the affected 
organ. Thus the blood from the stomach is black, coagulated, like 
coffee-grounds ; from the intestine, tarry. The general symptoms of the 
various degrees of external hemorrhage are similar to the symptoms of 
internal hemorrhage, which will be described later. Both vary with the 
rapidity of the flow of blood. If the bleeding is slow large quantities 
may be lost and give rise only to more or less profound ansernia. It is 
more difficult often to determine the source of hemorrhage. The mode 
of recognition of the anatomical varieties of hemorrhage will be dis- 
cussed under the respective systems which are the seat of the bleeding. 
Hemorrhage may take place in a cavity, as the stomach, bowels, or 
bladder, and after it has undergone changes cause symptoms of, and 
be discharged as, a foreign body. 

Internal hemorrhage presents vivid phenomena. The recognition of 
the hemorrhage is often impossible without some knowledge of the his- 
tory of the case, as will be spoken of later. The symptoms are com- 
plex. First, there is the symptom due to rupture of the vessel or to 
the filling of a tissue with blood — that is, pain. In the first instance it is 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 177 



sharp, severe, and of itself may cause shock. In the next place, the 
symptoms due to loss of blood arise. After pain, sudden prostration 
ensues ; pallor spreads rapidly ; the extremities become pallid ; they 
cool and later become cold ; a cold sweat breaks out on the forehead ; 
the features become pinched and shrunken ; the pulse becomes weak and 
rapid, and later thready, or disappears at the wrist ; the carotid pul- 
sates ; the heart throbs violently and a diffused impulse is seen, at first 
vigorous, soon like a slap against the chest wall, and then it fades away 
completely. On examination of the heart and vessels, so-called anaemic 
murmurs are heard. The patient is restless aud tosses to and fro. He 
sighs and yawns frequently. The respiration becomes slow and shallow. 
Nausea and at times vomiting may occur. He may faint at once, or re- 
peatedly, to be restored again and again, or soon fall into syncope, 
restoration from which does not take place. In the intervals between 
the syncopal attacks the mind is clear. When profound shock occurs 
there is dulness or stupor ; the intellect is dazed. Delirium and agita- 
tion may, on the other hand, be present. When the hemorrhage is 
profuse, convulsions may take place. The temperature of the body falls. 
If the patient has fever at the time, the temperature suddenly falls to or 
below the normal. It is thus seen that, in hemorrhage, the conditions 
syncope, shock, collapse take place. They may all occur in the same 
subject, or one or two may be absent. They may occur from other causes, 
which must be excluded. Sometimes the shock produced may be due 
to the cause which also produces the hemorrhage. The causes of shock 
are so potent that they serve to distinguish it from the collapse of 
hemorrhage. They are injury, anaesthesia, railway accidents, surgical 
operations, perforative peritonitis, strangulated hernia, intestinal ob- 
struction, profound mental impression, or pain. 

Shock from hemorrhage must be distinguished from concussion. In 
the latter the intellectual disturbance occurs at once and is more pre- 
dominant than circulatory symptoms. The absence of the usual phe- 
nomena of hemorrhage serves to distinguish syncope due to that cause 
from that due to the many well-known causes of fainting. 

The forms of internal hemorrhage sufficient in amount to have a 
probably fatal result, or at least to create alarming symptoms, are 
many. In the chest, diseases of the lungs or the aorta cause hemor- 
rhage. In concealed pulmonary hemorrhage the blood accumulates in 
a large phthisical cavity. When the aorta or an aneurism ruptures, the 
blood may enter the mediastinum or the pleura. Uuder these circum- 
stances the previous history is essential. Careful examination of the 
lungs, in a case which presents the above-mentioned symptoms of inter- 
nal hemorrhage, or of the heart or bloodvessels, must be made. Internal 
concealed hemorrhage into organs or cavities of the abdomen occurs in 
gastric, duodenal, or intestinal ulceration ; iu aneurism or in ulceration 
of large vessels, from septic inflammation about them. It must not be 
forgotten that alarming or fatal internal concealed hemorrhage may be 
due to haemophilia or purpura. 

II. Disturbances of Nutrition. 

Hypertrophy and Atrophy. (See Size, and Muscles.) 
Inflammation. Inflammation is a process largely attended by vas~ 

12 



178 



GENERAL DIAGNOSIS. 



cular alteration, but also with disturbance of nutrition. It may be acute 
or chronic. It is due to injury, mechanical, physical, chemical, or vital. 
The invasion of micro-organisms or the irritation of their products is the 
most frequent cause in cases that come within the province of the physi- 
cian. The symptoms are modified by the structure affected and the cause 
of the inflammation. The intensity and the character also modify them. 
The classical symptoms — -pain, heat, redness, and swelling — are symp- 
tomatic of the tissue process. In addition, we must add exudation and 
alteration of function. Pain varies in degree with the sensibility of the 
part. When accessible, it is increased by pressure or movement, or by the 
functional activity of the affected organ. Heat is detected by the hand or 
surface thermometer. It may be complained of by the patient, in abscess 
within the peritoneum or pyosalpinx, as a ball of fire. The temperature 
over an inflamed lung or pleura is higher than over the healthy side. 
Redness can only be observed in parts open to inspection, as the nasal, 
oral, faucial, and other cavities. Swelling is observed with the redness or 
detected by enlargement of the affected organ, if it can be measured by 
palpation or percussion. Exudation takes place from mucous surfaces, 
into serous cavities, into the connective or any affected tissue, into 
tubes or channels (heart and bloodvessels, lymphatics, etc.). The exu- 
dation gives rise to symptoms. Characteristic discharges from mucous 
surfaces; pressure and physical signs from accumulation into cavities; 
symptoms due to the obstruction of channels; grave pressure symptoms 
when impinging on nerves, on nerve centres, or nerve tracts (brain, cord, 
peripheral nerves) are due to exudation. The pressure symptoms are 
often more pronounced than the inflammatory in simple or tuberculous 
meningitis. Alteration of function : The symptoms cannot be detailed ; 
each organ and structure must be referred to. The function may be 
stimulated at first, but is soon perverted, or suppressed. 

General Symptoms. Fever is the general expression of the local pro- 
cess. It may be primary from reflex irritation of afferent nerves which 
influence the heat centre and disturb the thermo-taxic mechanism. 
It may be secondary ; the products of inflammation (pus, toxins, etc.) 
irritate the centres. The degree depends upon the cause. Considerable 
inflammation may occur without fever. 1 

Suppuration. The character of the fever indicates the variety of the 
inflammatory process. In most inflammations the fever is continuous. 
When suppuration commences or is present it becomes intermittent or 
remittent. The presence of suppuration is also made known by hectic. 
The fever is attended by chills and sweats. In suppuration there is 
leucocytosis. The appetite is lost or impaired. The urine contains a 
large amount of indican. The latter tests may be of service in deter- 
mining the nature of an inflammation about the peritoneum. Apart 
from the temperature range, the symptoms of fever are not modified by 
the process, save in degree. Septic inflammations are attended early 
by cerebral symptoms, prostration, and the typhoid state. 

As a corollary, when the symptom fever is present, local inflamma- 
tions must be sought for. Chronic inflammations may only give rise to 
altered function and cause exudation (swelling, effusion, etc.). 

1 Musser: "Abscess of Liver," Univ. Med. Magazine, 1892. 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 179 



Inflammation of Various Structures. The symptoms are modified by 
the structure. 

Inflammation of mucous membranes. Pain is uot excessive; heat is 
complained of (rectum); redness is marked and varies with the intensity 
from bright to dark red ; swelling is always present. In narrow chan- 
nels, as the nose, or the gall-ducts, it causes occlusion. The exudation is 
at first mucous, then muco-purulent, and then purulent. Before exu- 
dation there is a stage of dryuess. The microscopical appearance of the 
exudate varies with the anatomical character of the membrane affected. 
Its peculiar epithelium is always present, micrococci, pus, red cells ; 
from the lungs or liver, special crystals. The functions are impaired. 
Fever is usually not very high ; it is continuous. The causes are diret 
local irritauts or congestions from external impressions (cold ?). 

Inflammations of serous membranes. Pain is extreme and may 
cause collapse. Heat, swelling, and redness cannot be estimated. The 
surface temperature is raised. Exudation occurs after a brief dry stage. 
The cavities — pleura, pericardium, peritoneum, joints, cerebro-spinal 
canal — are tilled, causing mechanical symptoms and physical signs. 
Fever is excessive in some forms, depending on the cause. Function 
is impaired or abolished. General symptoms are more pronounced. 
Shock or collapse is common in peritonitis. The affections are always 
secondary to a general process (rheumatism), to infection, to disease of 
neighboring structures, or to Bright's disease, diabetes, cancer, scurvy, 
or other diathetic condition. 

Inflammation of muscles (rare), of connective tissue, and of glands are 
characterized by symptoms common to the morbid process, with alter- 
ation of function. 

Inflammation of bone and periosteum presents the same group of 
symptoms. The pain may be intense or of a dull aching or boring 
character. 

Inflammation of the heart and vessels is also attended by the cardinal 
symptoms. Pain, when the central organ is the seat of the disease, is 
not common, but in the arteries or veins is of frequent occurrence. 
The striking symptom, however, is the obstruction to the channels. 
It is characteristically seen in phlebitis, as of the femoral vein. (Edema 
of the leg, and cyanosis, tell of the obstruction. In the heart, the acute 
process or the results of the process lead to the occurrence of all the 
symptoms of obstructive heart disease. 

Inflammations of the nerves, the spinal cord, or the brain are fol- 
lowed more strikingly by pressure symptoms and the symptoms of 
the secondary degenerations of the inflammatory process. Hence, while 
pain and tenderness are present in the exposed nerves, abeyance, per- 
version, or abolition of function are the principal signs of inflammation 
of these regions. 

Inflammation of internal organs, lung, liver, kidneys, and pancreas, is 
made known by pain (minimum sign) and swelling (enlargement of 
liver), and by change in the function, indicated by modifications of the 
respective secretions as well as by functional or physiological symptoms. 

Local Death, Necrosis, and Gangrene. If nutrition is not 
complete, the life of the cells is endangered ; they soon die. The processes 



180 



GENERAL DIAGNOSIS. 



are known as necrosis or gangrene. The nutrition is annulled : 1 . By 
stoppage of the circulation ; 2. By the direct action of an irritant which 
destroys the cells ; 3. By abnormal temperature. A combination of the 
three causes produces gangrene quickly. Stoppage of the circulation 
may be due to an embolus or thrombus, or to stagnation by pressure, or, 
independently, in capillary stasis. Sloughing and " bedsores" ensue 
in the latter instances; gangrenous eschars in the former. The cells 
are destroyed by corrosives and caustics, by heat and cold, by bacteria. 
Where decomposition takes place, as in retained and infiltrating urine, 
cell destruction and sloughing ensue. All pathogenic bacteria cause 
necrosis to greater or less degree. Frost-bite and burn illustrate the 
destructive power of abnormal temperature. The symptoms are local. 

Nerve lesions, trophic disorders, produce necrosis. Decubitus is a 
form of necrosis which arises in spinal cord diseases. The sloughing 
is extensive and rapid. Trophic disorders cause paralytic hypersemia, 
and hence necrosis. 

The part that debility, cachexia, and feeble circulation play in assist- 
ing the local changes must not be forgotten. 

Gangrene of internal structures concerns us. Such form is nearly 
always due to stoppage of the circulation. It is seen in constriction of 
the intestine, from hernia, or obstruction. It occurs in phthisis from 
thrombi. Clinically, we see it frequently in diabetes. The lung, the 
brain, the intestines, are most frequently affected. 

The symptoms of necrosis or gangrene are modified by the tissue 
and function involved. If external, the decomposing structures emit 
a foul odor, there is rapid prostration and the development of the 
typhoid state. Fever ensues because of the intoxication by decompos- 
ing substances — saprsemia. Often the symptoms are latent. A man 
aged sixty in my ward was about all the time. He died suddenly of 
pulmonary hemorrhage, the result of gangrenous ulceration of a large 
vessel. At the autopsy gangrene of the lung was found. The only 
symptom was the characteristic odor. In the course of inflammatory 
processes its onset is frequently attended by the cessation of pain, the 
occurrence of the peculiar odor, if accessible, and the development of 
exhaustion and the typhoid state. The character of the discharge points 
to gangrene. When the lungs are affected, the expectoration is like 
prune juice; when the bowels, the discharge is dark and putrid. 

Fever is a morbid process, with the cause and symptomatology of 
which the student must be familiar. It has been fully treated of in a 
preceding section. (See Fever and Infectious Diseases.) 

The Degenerations. The symptomatology varies with the form 
of degeneration and the organs affected. The general economy is in a 
state of prostration for the same reason that the degenerations are 
present. Albuminous degeneration occurs in fever, and causes the weak 
heart and defective gland action. The weak heart of the convalescent 
period in diphtheria and other infective diseases is well known. 

Fatty Degeneration. Fatty infiltration or lipomatosis is seen in 
the "fat" heart of brewers, the enlarged liver, the excess of fat in the 
abdomen, etc. The affected organs are enlarged, they are functionally 
weak. Fatty infiltration of organs is recognized by its ^etiological asso- 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 181 



ciations. If with the above conditions the liver is enlarged or the heart 
weak, or both, we may expect to find this degeneration. There is 
enlargement of the affected organ, which is painless, smooth, not 
usually soft on palpation. The condition occurs at any age, but usually 
in later life. Emaciation may not occur. Lithsemia is common in fatty 
infiltration. In alcoholic subjects living sedentary habits, in subjects 
who eat an excess of fatty foods, in overfed and pampered children, and in 
tuberculosis, it is commonly seen. In fatty infiltration the cells are 
not destroyed. In fatty degeneration there is cell destruction. The 
brain, the heart, the kidneys in Bright's disease, the liver, all undergo 
degeneration. It may be due to phosphorus poisoning or snake-bite. It 
is seen in acute yellow atrophy of the liver. 

Amyloid Degeneration. This is rarely confined to one organ of 
the body ; many are affected. The causes are syphilis, malaria, tuber- 
culosis, and prolonged suppuration. The liver and spleen are enlarged, 
hard, smooth and painless. There is great pallor, oedema of the feet and 
face. There is anaemia, but no fever. The kidneys are affected, hence 
polyuria and low specific gravity of the urine ; a few casts are found. 
The bowels are likely to be loose from degeneration of the intestinal 
walls. It occurs at any age. The diagnosis rests on the presence of a 
cause, the painless enlargement of organs, the pallor, the polyuria. 

Fibroid Degeneration. This is not a degeneration, but rather an 
overgrowth of connective tissue with coincident primary or secondary 
atrophy of the parenchyma. The function of the organ is impaired or 
abolished. The increase of connective tissue in the nerve structures is 
known as sclerosis, in the liver or kidney as cirrhosis. In the artery 
it leads to the changes known as endarteritis. Whatever the pathology 
may be, particularly as to the question whether atrophy of cell elements 
of the affected structure is primary or secondary, nevertheless the con- 
dition is productive of serious, even grave, symptoms. It is part of the 
senile process. It leads to the manifold symptoms of endarteritis ; it is 
the cause of many nervous affections which will be treated of in their 
proper sections. The varied phases of so called interstitial nephritis 
are due to the fibroid change primarily in the kidneys, and secondarily 
in the arterial system. In the lungs it attends emphysema, and may 
be productive of that condition. The fibroid heart arises because of 
it. Tubes and channels are closed by the same process as in fibrous 
stricture of the duodenum. Wherever situated its development means 
gradual abolition of function. 

Mucous Degeneration. This form of degeneration is seen in 
myxcedema, previously described. The albuminous intercellular sub- 
stance is replaced in the connective tissue by mucin. 

Pigmentary, calcareous and colloid degenerations are local morbid 
processes without symptoms beyond those due to the primary affection. 

Tumors and New Growths. Tumors other than cancer or sar- 
coma, produce symptoms only mechanical and must be considered in 
their special section. They are due: 1. To the tumor (foreign body). 
2. To obstruction of any channel in near relation. Cancer and sar- 
coma are accountable for a group of symptoms to which the term 
cachexia has been applied. 



182 



GENERAL DIAGNOSIS. 



It is true they produce local symptoms. This is most striking when 
the growth develops in structures which must be destroyed from in- 
crease in its size, as in the brain or spinal cord, or where tubes or chan- 
nels may be closed, as in cancer of the stomach or oesophagus. (See 
Special Diagnosis.) 

Local symptoms may precede the general symptoms. On the other 
hand general symptoms may arise, the local cause for which cannot be 
discovered. The local symptoms of cancer of any particular organ 
are variable and dependent upon the anatomical nature and physiologi- 
cal offices of this organ and upon their anatomical relation with surround- 
ing organs. This class of symptoms will be referred to in the section 
on special diagnosis. They are symptoms due to gradual abolition of 
the function of the organ, and closure of the channels in connection 
with it, as the intestinal canal, the pharynx, or the hepatic ducts. A 
few symptoms are common to the cancerous process. They may or 
may not be present; in the large majority of cases one or more are 
present ; they should always be sought for in order to confirm a diag- 
nosis of cancer. 

1 . Pain is a common symptom, recognized by peculiar characteristics 
in most cases : (a) It is sharp and lancinating; (6) it is paroxysmal; 

(c) it is increased by irritation, as food when the stomach is affected ; 

(d) it is increased by functional activity, especially if movement is ex- 
cited, as speaking or swallowing in carcinoma of the larynx or pharynx 
respectively. 

2. Hemorrhage is a common occurrence in carcinoma. If the malig- 
nant mass is in communication with the exterior by channels, the blood 
may be discharged per vias naturales. In malignant disease of the 
upper air-passages or in the lungs, hemorrhage is likely to occur. In 
gastric carcinoma it is common. Its occurrence in uterine cancer is 
well known. If the organs are not connected with the exterior, but 
give rise to exudations or transudations, the latter are frequently 
bloody, as in carcinoma of the pleura or peritoneum. 

3. Abnormal Discharge. This particularly occurs in cancer of the 
hollow viscera; of the canal structures. The discharge is the result of 
inflammation, suppuration, and necrosis, and particularly microbic in- 
flammation. It is recognized by its more or less bloody character and 
by its odor. The latter is peculiar. It is most offensive aud penetrat- 
ing, and, particularly in uterine cancer, is almost pathognomonic. Even 
with the utmost attention to cleansing, it cannot be removed. 

4. Tumor. It may be readily detected or elude all search. Some 
swelling is certainly present. It is recoguized by external examination, 
by the objective physical signs of enlargement or change of contour of 
the affected organ. 

5. Foreign body. The growth gives rise to symptoms, similar to 
those that are present when a foreign body is fixed in any portion of 
the hollow viscera, as the respiratory tract, the gastro-intestinal, includ- 
ing the hepatic and the genito- urinary tract, a. Through reflex in- 
fluence an attempt is made by the patient for its removal, hence cough, 
vomiting, diarrhoea with tenesmus, repeated and painful micturition 
with tenesmus, etc., the particular symptoms varying with the organ 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 183 



affected — are induced, b. Obstruction of the channels, with the many 
symptoms that arise therefrom, depending upon the location of the 
growth. 

6. Temperature. A morbid process is often recognized by its nega- 
tive symptoms, if the term may be used. Thus, fever is absent or the 
temperature is subnormal. 

7. The Cancerous Cachexia. Wherever situated the disease sooner or 
later is attended by extreme general symptoms which are in a measure 
striking. It is to be admitted that cases of carcinoma often occur 
without marked cachexia, a. One symptom may always be looked 
for ; it is emaciation. It may be rapid or may be gradual and extend 
over one to two years; toward the end it is always rapid. Ultimately, 
if the patient does not succumb to other conditions, it presents an 
extreme picture. The eyes are sunken, all normal accumulations of fat 
disappear. The fat in the rectal fossa? disappears, causing deep 
depression of the rectum. The abdomen is retracted. The appear- 
ances are probably more striking in cancer of the oesophagus than 
in any other organ, b. Pallor— & peculiar hue is seen (see Facies); 
this may be absent. e. Anoemia, with breathlessness, palpitation, 
vertigo, d. Exhaustion. This progresses with emaciation. It may 
be the first symptom. Progressive weakness, without fever or local 
disorder to account for it, is often seen. Toward the end it be- 
comes so extreme as to forbid exertion, e. Malnutrition. Evidences 
of malnutrition are seen. The skin is hard and dry. Its elasticity is 
impaired. It becomes the field for parasitic invasion. Tinea and other 
parasites may flourish. Bacteria invade the susceptible areas ; boils 
occur in full degree. The secretions are perverted. In the mouth 
ulcers develop ; the fungi of this situation (throat, etc.) become more 
active; the gums are inflamed. In the later stages the " typhoid state" 
(see Fever) may ensue. If the gastro-intestinal tract is invaded symp- 
toms of acute intoxication may arise. 

8. Metastasis. We are often aided by the occurrence of this event, 
particularly glandular involvement. In gastric carcinoma, evidences of 
secondary hepatic disease or enlarged glands above the left clavicle ; in 
rectal carcinoma, secondary hepatic cancer points to the primary process 
most conclusively. In many instances the presence of cancer is recog- 
nized by the metastasis even when the primary growth cannot be 
recognized. 

The diagnosis rests upon the above conditions. In obscure cases, the 
age, the sex, the associate pathological conditions, the duration of the 
disease, are of service. Cancer usually occurs after forty, or some 
authorities say, after fifty years of age. The female sex is most fre- 
quently affected. It may be associated with a history of previous lesion 
or irritation, as ulcer in vaginal, gastric, or rectal cancer; the irritation 
of teeth or a pipe in labial and lingual cancer ; of gall-stone, in cancer 
of the bile-ducts ; of renal or visceral calculus in disease in that situa- 
tion. A disease of grave and malignant character, the duration of 
which is over eighteen months or two years, is not, in all probability, 
cancer. 



184 



GENERAL DIAGNOSIS. 



Morbid Processes in Tubes or Channels. The effects produced 
by obstructions. 

The morbid processes previously described have nothing to do with the 
lesions of the anatomical structure which makes up the channel. Ref- 
erence is to be made only to obstruction of the canals. The symptoms 
derived from obstruction of the bloodvessels and lymph channels, cyan- 
osis, oedema, gangrene (thrombosis and embolism), have been described. 
Sufficient stress was not laid upon one secondary symptom group, a 
group which arises in obstruction of all channels. The symptoms are 
due to hypertrophy in front of the point of obstruction. In the cases 
of vascular obstruction the hypertrophy is seen in the heart and the 
arteries. (See Diseases of the Heart.) 

In obstruction of other tubes or channels there is observed in more 
or less degree, first, hypertrophy in front of the obstruction ; second, 
regurgitation, damming up of material which normally passes through 
the channels ; third, atrophy and cessation of functional activity beyond 
the point of obstruction ; fourth, cessation of the flow T of the normal 
fluid along the canal obstructed ; fifth, dilatation of the hypertrophy 
which took place primarily ; sixth, degeneration, ulceration, low-grade 
inflammation (bacterial), secondary rupture of the affected viscera The 
morbid anatomist can readily point out examples of the morbid changes 
that are sequential to obstruction. Thus in cancer of the oesophagus 
there is hypertrophy of the muscular coats, regurgitation of food, 
atrophy of the stomach, dilatation with accumulation of food, secretions 
from the glands of the oesophageal mucous membrane, secondary ulcera- 
tion, rupture into the luugs, with gangrene or pneumonia. In obstruc- 
tion at the pylorus there is, first, hypertrophy ; second, accumulation, 
regurgitation ; third, intestinal atrophy ; fourth, dilatation of the stom- 
ach, with its train of symptoms. In obstruction of the biliary chan- 
nels, or the bladder, or ureters, the same secondary conditions arise, 
plus obstruction to the flow of bile or urine. Secondary symptoms arise 
from accumulation of the non-escaping fluids. Subjective symptoms, it 
may be said, are not marked, but, if present, are pain and difficulty in 
the performance of the usual functions. It need scarcely be said the 
obstruction sometimes gives rise to symptoms which are due to the 
abnormal obstructing material which acts as a foreign body. The 
symptoms are reflex and depend entirely upon the seat of the foreign 
body. The symptoms are most marked when the obstruction is due 
to disease outside of the walls or to obstruction by occlusion within 
the walls. 

The causes of obstruction in whatsoever channel situated are, first, 
pressure from disease outside (growths, hernia) ; second, disease of the 
walls, with contraction ; third, occlusion by a foreign body, as gall- 
stone, renal calculus, worms, or other material, depending upon the 
channel obstructed. 

In all cases of obstruction, nasal, faucial, laryngeal, bronchial, 
(esophageal, gastro-iutestinal, biliary, renal, or pancreatic, look for the 
symptoms of the secondary morbid change. Each form of obstruction 
will be considered elsewhere. (See Special Diagnosis.) 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 



185 



The Bloodvessels. Blood-pressure. It must not be forgotten that 
the bloodvessels are in a measure distinct from other tubes, although sub- 
ject to the same laws, physiological and pathological. They contain fluids 
and have a continuous function by which the fluids are propelled. They 
are subject to the laws that govern the flow of fluids under all circum- 
stances in nature. Any derangement or disease will cause violation of the 
hydrostatic or hydrodynamic laws. Fluids within vessels exert pressure. 
Pressure produced by the weight of the fluid is known as the hydro- 
static pressure ; produced by the flow is known as the hydrodynamic 
pressure. Pressure can be gauged and its degree ascertained by proper 
instruments. In the case of fluid in the bloodvessels, it is called the 
blood -pressure. The blood-pressure is estimated by the educated finger 
on the pulse and by the sphygmograph. A certain definite pressure is 
always present in health. It is subject to slight fluctuations, but tracings 
with a sphygmograph follow a definite course. In the description of 
the pulse, modifications of blood-pressure will be given in detail ; it is 
sufficient here to say a few words regarding hydrostatic and hydrody- 
namic pressure. 

Hydrostatic pressure is modified by the weight of the fluid. It is of 
importance in the veins only, and especially those of the lower limbs, in 
pathology. When the pressure is increased, first, because of increased 
weight, or second, because of loss of power to support the pressure (the 
most common), varicose veins and venous congestion arise. Inflamma- 
tions of the lower limbs are attended by venous accumulation and 
followed by ulceration. Dropsies in these portions arise more readily 
for these reasons. The common occurrence of gout in the feet may 
arise from slowness of the circulation. 

Hydrodynamic pressure is variable. Its changes indicate increase or 
diminution of blood-pressure. The bloodvessels are resisting elastic 
tubes ; the resistance is always equal to the pressure within, hence blood- 
pressure and arterial tension are equivalent terms. We speak of increased 
or diminished pressure, or correspondingly of high or low tension. Now 
the hydrodynamic or blood-pressure depends upon, 1, variations in the 
volume of blood ; 2, variations in the capacity of the vascular system ; 
3, facility of the capillary circulation ; 4, the force of the heart. The 
tension of the artery is dependent upon the same factors. 

1. Variations in the volume of the blood, a. Volume increased. 
Causes, absorption of fluid after meals or driuking more fluid. Result, 
increased blood-pressure and iucreased tension. Controlled in health by 
action of the vasomotors relaxing the vessels, causing their enlargement, 
and by enlargement of the veins, b. Volume diminished. Cause, 
hemorrhage, serous purging. Result, diminished blood-pressure, low- 
ered tension. Controlled in health by contraction of arteries through 
vasomotor nerves. In hemorrhage the loss of blood produces ausemia. 
The latter is a stimulant to the vasomotor centre in the medulla, and 
produces contraction of peripheral arteries and high tension. 

2. Variations in the capacity of the vessels, a. Diminution of the 
capacity of the blood channels (volume of blood not lessened). Cause: 
cutting off of a vascular area by ligation or obstruction, by narrowing 
the calibre of the walls as in arterial spasm or endarteritis, by disease of 



186 



GENERAL DIAGNOSIS. 



the kidneys lessening channels in the aortic circuit, or disease of the aorta 
causing obstruction to the outflow of blood. Result : increased pressure, 
high tension. Controlled by normal regulating vasomotor apparatus, 
or by diminution of the volume of blood, b. Increase of capacity of 
blood channels. Cause, relaxation of muscular coats of vessels. Re- 
sult, diminished blood-pressure, lowered arterial tension. Controlled 
by contraction of vessels or increase in amount of blood. In shock, the 
vasomotor sympathetic system of the splanchnic arteries is so disturbed 
that the arteries are dilated and all the blood is sent into the abdominal 
vessels (fall of pressure). 

Mode of action of the vasomotor apparatus. Centres in the medulla, 
in the spinal cord, and in the sympathetic ganglion control the vaso- 
motor nerves, which influence hydrodynamic pressure. 1. If the 
centres are stimulated, tonic contraction of the vessels is produced. This 
may be general or local. Increased pressure or heightened tension is 
the result. It may be a reflex from the periphery, or due to some state 
of the blood. 2. If the centres are paralyzed, or inhibited, or cut off 
from the arteries, the latter become relaxed (dilated). The pressure is 
lowered, the tension is less. Shock, pain, certain drugs, reflexes (prob- 
ably) produce inhibition. 

3. Facility of capillary circulation. Obstruction to outflow of blood 
from capillaries into veins increases blood-pressure. Cause, the same as 
when arteries contract. Result, increased blood-pressure, high tension. 
Regulated in same manner as arteries. Relaxed capillaries produce 
opposite conditions. 

4. The force of the heart, a. Heart's action (left ventricle) increased. 
Cause, hypertrophy, palpitation. Hence greater force of blood impact, 
greater resistance by arteries. The tonic resistance narrows the calibre 
of the vessels. Result, increased pressure, higher tension, b. Heart's 
action . weakened. Hence, less force of blood, less resistance. Result, 
lessened pressure, low tension. 

The recognition of variations in tension. (See Pulse.) 

1. High arterial pressure or tension. By (a) incompressibility and 
tension of the arteries ; (6) accentuation of the aortic second sound ; (c) 
prolongation of the left ventricle first sound ; (d) increased flow of urine, 
pale and watery ; (e). characteristic pulse tracing by sphygmograph. If 
the high tension is permanent, (/) hypertrophy of the heart; (g) 
atheroma, more or less. 

2. Low arterial pressure or tension. By (a) soft, compressible, often 
dicrotic pulse ; (6) enfeebled sounds, aortic second and left ventricle ; (c) 
scanty high-colored urine ; (d) special pulse tracing. If permanent, 
stases, congestions, cyanosis, with geueral weakness and impaired nutri- 
tion. 



PART II. 

SPECIAL DIAGNOSIS. 



CHAPTEE I. 

DISEASES OF THE NOSE AND LARYNX. 
The Nose. 

The symptoms of disease of the nose are due to the function and the 
structure of the organ and the morbid process which affects it. Physio- 
logic symptoms : The sense of smell may be impaired, and symptoms 
due to obstruction of the canal occur in more or less degree in nasal 
affections. Obstructive symptoms : On account of obstruction more or 
less marked, retention of secretions occurs. The secretions are exposed 
to infection from without by bacteria. Putrefaction and fermentation 
occur and give rise to offensive odors. More serious is the effect of the 
obstruction on the rest of the respiratory tract. On account of nasal or 
post-nasal obstruction, the air must pass through the mouth. The patient 
becomes a mouth-breather, and, in addition to the change in the face that 
takes place, the voice changes, snoring is common, and mastication is 
interfered with ; and, notwithstanding that the mouth is used as an air- 
passage, there is a diminution in the amount of air passing to the lungs. 
As a result a vacuum is created which is compensated for by external 
pressure. In children the result of this is marked deformity of the 
chest, leading to the development of the " chicken-breast/' The sides 
of the sternum are depressed, the transverse groove is increased, the 
sternum itself is projected forward. The general symptoms that accom- 
pany such interference with breathing will be referred to again. 

Symptoms due to the Anatomical Structure. The nose is an open 
space or series of air-spaces lined with mucous membrane. The mucous 
membrane is the frequent seat of microbic inflammation, as noted in 
hay fever, influenza, or measles. Most of the nasal symptoms are due to 
affections of the mucous membrane. This membrane is subject to affec- 
tions that are common to all mucous membranes, and the subjective and 
objective symptoms are similar to those that arise in other organs, modi- 
fied by the function and the anatomical arrangement of the membrane. 
The richness of the membranes in bloodvessels and glands is the cause 
of one of the symptoms, namely, the discharge. Moreover, the difficulty 
of removing the discharge on account of the various cavities in the nose 
in which they are pent up leads to putrefaction and the occurrence of 



188 



SPECIAL DIAGNOSIS. 



odor. Because the air is constantly passing over the parts, discharges 
are very liable to become dry, and hence crusts and scabs form. The 
vascularity of the structures of the nose is also the cause of the develop- 
ment of symptoms. The bloodvessels are richly supplied with nerves, 
which cause them to contract or dilate on comparatively slight provoca- 
tion, by reflex action. Chilliness of the body, or of local areas of the 
body, chilling of the extremities, and other peripheral impressions, are 
followed by congestion of the nasal mucous membrane, which may go on 
to inflammation. The vascularity predisposes to hemorrhage. The nose 
is richly supplied with nerves (in addition to the olfactory nerve) which 
are susceptible of various irritations or impressions — impressions made 
by the air laden with unusual material, as fumes of a chemical nature, 
emanations from animals or from plants, and certain materials not yet 
isolated, which are decidedly irritant to them. A local source of irri- 
tation often occurs, by polyps and adenoid growths, and foreign bodies, 
or enlarged bone. The nerves are connected by a mechanism which is 
directly connected with the centres in the medulla, particularly so the 
pneumogastric. The effect of peripheral nasal irritation may be felt re- 
flexly in the area of distribution of that nerve; hence from an unpleasant 
odor we may have the sudden occurrence of nausea or vomiting. But 
of more striking and frequent pathological significance is the occurrence 
of asthma, or sudden dyspnoea, on account of reflex excitation of the 
pulmonary division of the pneumogastric nerve. 

Morbid processes in the nose are symptomatic of some general affec- 
tions. We will not speak again of the occurrence of asthma, or of de- 
formity of the chest and general ill-development. Acute inflammations 
are significant of the exanthematous diseases, particularly measles. An 
acute inflammation (as pointed out by Meigs) in which there is great 
obstruction of the nares, with an abundant, thick discharge, is a com- 
plication or early symptom of Bright's disease, that may portend the 
early onset of uraemia. Qhronic inflammations may be due to syphilis 
and chronic infection from other causes. 



The Data Obtained by Inquiry. 

The Subjective Symptoms. These often cause extreme distress, 
but do not lead to a fatal termination. The general subjective symptoms 
are allied to those of the inflammations of other mucous membranes. 
Lassitude occurs when there is fever. It is a frequent precursor of rhi- 
nitis, and is pronounced in croupous and diphtheritic rhinitis ; extreme 
prostration may attend the latter. Chilliness following the lassitude, or 
rigor, may occur in the same class of cases. If distinct rigors occur, an 
abscess in one of the cavities may be suspected, if the subjective and 
objective symptoms point thereto ; or glanders may be present. 

Fever. This occurs in the inflammations ; it is never marked, and is 
not of diagnostic significance. It is more severe in glanders than in any 
other affection of the nares. It is of low type in diphtheria, and of 
hectic character when there is abscess. High fever, associated with 
inflammations of the nose point to the occurrence of one of the exan- 



DISEASES OF THE NOSE AND LARYNX. 



189 



themata as the primary cause of the rhinitis. Foreign bodies in the 
nose may cause fever of an inflammatory character. 

Local Subjective Symptoms. Pain varying in degree occurs in 
all of the acute affections of the nose. Its seat and character are of some 
diagnostic significance. A smarting or burning pain at the root of the 
nose accompanies acute rhinitis and attends post-nasal catarrh. The 
pain is diffuse and indefinite in dry catarrh and in diphtheria. The 
most severe pain occurs when foreign bodies are present in the nose and 
in cases of glanders and primary syphilis. Foreign bodies of a vege- 
table nature by swelling and germinating induce pain, which increases 
gradually in intensity. 

Pain over the Frontal Sinus. Pain over the sinus is more severe 
than in the nose when there is inflammation of these cavities. It is 
sometimes so intense and agonizing as to cause serious general effects. 
Pain may also be located in the cheek on account of a secondary affection 
of the autrum. In disease of the nose, if the pain radiates to the ear 
the Eustachian tubes are probably involved. 

Disturbance of the Sense of Smell. Anosmia and Parosmia. Loss 
of smell, or anosmia, occurs to a moderate degree in all the inflam- 
matory and obstructive diseases of the nose. The intensity depends 
upon the degree of change in the mucous membrane. It may also be due 
to disease of the nerves or the olfactory centre in the brain. Parosmia 
is the perception of abnormal odors, and may be a neurosis or psychical 
difficulty entirely, and hence purely subjective, or there may be inability 
to distinguish an odor when presented to the nostril. All odors may 
appear the same, or agreeable odors may appear to the patient very 
disagreeable. In addition the patient may complain of the perception 
of an odor in connection with the nasal disease with which he is affected. 
Parosmia is due to involvement of the olfactory nerves. 

A sense of dryness is a symptom of which the patient frequently 
complains, particularly in the early stages of acute rhinitis and through- 
out the entire course of a dry catarrh, or atrophic rhinitis. 

Obstruction or Stenosis. This causes sometimes the greatest discom- 
fort to the patient. There may be simply a sense of stuffiness and full- 
ness in the nasal and frontal region, or complete obstruction, causing 
inability to breathe through the nose. It occurs in all the obstruc- 
tive diseases of the nose and naso-pharynx ; in acute rhinitis, in chronic 
inflammation (except the atrophic form), in hypersemia, the hypertro- 
phies, polyps, tumors, deviations of the septum, foreign bodies and 
adenoid vegetations. 

Deafness is complained of when the Eustachian tubes are invaded or 
obstructed from inflammation or stenosis. When associated with anos- 
mia it may be of central origin. Tinnitus aurium frequently accompanies 
the deafness. 

Cough. This is of an irritative character. The discharge may pass 
into the pharynx and the larynx, setting up an irritation on account of 
which cough takes place. It occurs, therefore, in the catarrhs and 
obstructive diseases, and is not diagnostic of any nasal condition. When 
the nostrils are too wide, as in atrophic rhinitis, cough may occur be- 
cause irritating particles are admitted through the widened aperture. 



190 



SPECIAL DIAGNOSIS. 



The Data Obtained by Observation. 

The Objective Symptoms. Of the general objective symptoms, 
fever has been noted. In certain affections of the nose defective devel- 
opment of the general system is observed. This is particularly the 
case in adenoid vegetations of the naso-pharynx in children. (See 
Diseases of the Pharynx.) 

Local Examination. The Exterior. The external appearance of 
the nose is one of diagnostic significance when marked deformity takes 
place. Its true shape is changed in myxoedema (q. v.), but is not of 
consequence except in association with other symptoms of that affection. 
The change in the shape of the nose, of special significance, is seen 
in cases of disease of the bone due to syphilis. The bridge of the nose 
is sunken, or depressed. It must not be confounded with the depres- 
sion that occurs in fracture. The nose may be broadened in cases of 
tumors of an expanding nature in the nasal cavities. The local change 
soon extends to the cheek. The nose also is the seat of eruptions, as 
acne and hyperemia, but they are usually of local origin. The latter 
may be suggestive of a gouty diathesis. 

Internal Examination. The examination of the cavities of the nose 
consists of two procedures, both of which are necessary to determine 
with accuracy the condition of the organ. These are : 

1. Anterior Rhinoscopy. For this are needed a good light, a nose 
speculum of some form, probes, a 10 per cent, solution of cocaine, and 
a head mirror with central opening. 

The examiner proceeds as follows : The patient is seated facing the 
surgeon, with the light behind and at one side of the head, as nearly 
as possible on a level with the eye of the operator. He must sit with 
shoulders and head a little forward. The operator adjusts his head 
mirror so that the central aperture is in front of his own eye and the 
reflected light falls on the nose of the patient. It is very important for 
nose examination that the operator look through the aperture and not 
under the mirror. The speculum is then taken in one hand and the 
nostril dilated so that the view of the interior is unobstructed. Do not 
try to dilate the bony part of the nose, but only the nostril. Proceed 
from before backward with the examination, carefully focussing the 
light on each part in succession, and gradually tilting the head of the 
patient backward. Thus the floor of the nose, the septum, inferior 
turbinated bones, middle turbinated bones, and sometimes the superior 
turbinated bones, are brought into view successively. In a broad nose 
one may at times see the posterior wall of the pharynx, which is dis- 
tinguished by its peculiar wave-like movement when the patient 
swallows. The use of the probe is important, and without it no posi- 
tive diagnosis cau be made. With the probe the operator tries the 
condition of the mucous membrane, tests the consistency of tumors or 
hypertrophies, and so judges of the character of the condition. After 
this the enlarged parts should be touched with the cocaine and the result 
observed. Contraction of a swelling under its influeuce proves its 
vascular origin. 



DISEASES OF THE NOSE AND LARYNX. 



191 



2. Posterior Rhinoscopy. This is the most difficult part of the ex- 
amination, and requires much practice to enable the operator to accom- 
plish it satisfactorily. The instruments needed are a tongue depressor, 
head reflector, two sizes of throat mirrors, a palate hook or flat strings 
for holding forward the soft palate, and a curved applicator for cocaine, 
or a spray bottle with tip turned upward. 

The patient is seated as before, the tongue held down by the tongue 
depressor, and the patient is told to breathe freely through both mouth 

Fig. 21. 



>v: ■■■■ vi 




Diagram showing rhinoscopic mirror in position. (Bostvorth.) 



and nose. The light is directed into the pharynx and a mirror of the 
largest possible size inserted carefully behind the soft palate. The 
proper angle and the movement necessary to bring all parts into view 
can only be learned by practice. As a rule, it is best to hold the handle 
well up at first and note the condition of the vault of the pharynx, then 
gradually depress it, examining the choanse from above downward. Do 
not keep the mirror too long in the throat. It is better to insert it several 
times than to weary the patient by attempting to see everything the 
first time. After the choanal have been examined a turn of the mirror 
to either side will bring into view the orifices of the Eustachian tubes. 



192 



SPECIAL DIAGNOSIS. 



and the examination is complete. Where it is impossible to see the 
posterior nares after repeated attempts, one must first seek to accustom 
the patieut to the presence of the instruments ; if this fails it may be 
necessary to resort to the palate hook or the cords to hold the uvula 
forward. The best hook is White's. It is necessary to apply cocaine 
to the soft palate before inserting the hook. Another plan which is 
preferred by some is to take the fiat cords used for corset laces, soak 
them in mucilage and dry them. These are then stiff enough to pass 
through the nostril, yet flexible enough to pull down and out through 
the mouth with forceps. Then by drawing forward both ends the soft 
palate is pulled out of the way. This is almost always necessary when 
applications are to be made to any spot in the pharynx. 

Sometimes a view of the posterior nares may be obtained by making 
the patient breathe in short, quick gasps, by which the uvula is released. 
In ordinary breathing it is often tightly pressed against the posterior 
wall of the pharynx. 

Fig. -22. 




12 

Rhinoscopic image. 



1. Vomer or nasal septum. 2. Floor of nose. 3. Superior meatus. 4. Middle meatus. 5. 
Superior turbinated bone. 6. Middle turbinated bone. 7. Inferior turbinated bone. 8. Pharyn- 
geal orifice of Eustachian tube. 9. Upper portion of Rosenmuller's groove. 11. Glandular tissue 
at anterior portion of vault of pharynx. 12. Posterior surface of velum. (Seiler.) 

Through examination by the above methods the nature of the dis- 
charge is ascertained, and the presence of ulceration or perforation and 
the condition of the entire nares determined. Deviations of septum, 
enlargement or contraction of turbinated bones, the presence of foreign 
bodies or abnormal growths, are also ascertained in this manner. 

Palpation. In palpation the finger or probe is used. By the latter 
the character of enlargements or tumors, and the patulency of foramina 
may be determined. The character of the mucous membrane as to indura- 
tion and the presence of caries or necrosis is estimated. By the finger 
the naso-pharynx is palpated to confirm the results of rhinoscopy. In 
this manner adenoid vegetations and hypertrophy of the inferior 
turbinated bones are detected. The finger should be protected by the 
use of a mouth-gag or by a jointed thimble. 

Color of the Mucous Membrane. The observer may find it unusually 
pale. This is seen in tuberculosis and in atrophic rhinitis. If a 



DISEASES OF THE NOSE AND LARYNX. 



193 



protuberant mass is observed to be transparent and shining, as well as 
pale, it is due to a polypus. If the mucous membrane is bright red it 
may be due to acute inflammation, to glanders, or to syphilis. It is 
dull red in chronic catarrhs and caseous rhinitis. The coatings of the 
mucous membrane are of significance. If a dry mucus covers the part 
it is due to dry catarrh ; on the other hand, a dirty-gray membrane 
is indicative of diphtheritic rhinitis. 

Ulceration of the Mucous Membrane. Ulceration is usually a mani- 
festation of lupus, tuberculosis, or tertiary syphilis. In lupus the 
ulceration has extended from the exterior. Tuberculous ulcers are 
usually found in the septum. They present a whitish-gray surface with 
elevations of infiltrated tissue. They are liable to bleed on the slightest 
provocation. The mucous membrane surrounding them is torn. 
Tubercle bacilli can be found in the scrapings from the ulcer. In 
syphilis the ulcers are situated anywhere in the nares. They may be 
mere superficial excoriations, or deep serpiginous ulcers surrounded by 
an inflammatory zone. Caries may be detected with a probe. The 
ulcerated surfaces are covered with a dry, greenish crust. 

Neuro-paralytic ulcers are painless, spread rapidly over considerable 
surface, and follow paralysis of the fifth nerve. They are dry and 
sluggish ; they do not extend to the skin. Post -febrile ulcers follow 
measles, scarlatina, typhoid, and variola, and are due to rupture of 
small abscesses, with the subsequent formation of ulcer. They are 
usually anterior on the septum or inside the alse, and scabs form over 
the surface. They are very irritable. Ulcers may perforate the 
septum or the floor of the nose. They are usually due to syphilis. Simple 
perforating ulcer of neuro-paralytic origin may also occur. 

Secretion. The study of the secretions is of diagnostic significance. 
They may be liquid, semi-solid, or solid. The liquid secretions may be 
serous, mucous, or purulent. Serous secretions occur in acute rhinitis, 
hay fever, and idiopathic rhinorrhoea, and follow bursting of cysts. 
The secretion of mucus occurs in the later stages of inflammation of 
the mucous membrane and in chronic forms. A muco-purulent secre- 
tion is seen in chronic rhinitis, and pure pus in abscesses of the septum 
or cavity. A discharge of blood is known as epistaxis (see page 194;. 
The semi-solid secretions may be due to mucus alone, or to blood-clots 
mingled with serum or with pus. The latter occur in atrophic and 
hypertrophic catarrhs. A semi-solid secretion is seen in Caseous 
Rhinitis. On examination the cavities are filled with cheesy matters, 
easily broken up with the probe. The mucous membrane is dull red. 
The material is discharged in masses at intervals through the mouth or 
nostrils, relieving the previous extreme stenosis. If neglected for a 
long time, deformity of the face and disease of the bones and cartilages 
of the face ensues from pressure. 

The solid secretions may be mucous crusts, as in acute and chronic 
catarrhs, blood crusts after epistaxis and traumatism, membrane in 
diphtheritic rhinitis, sloughs from ulcers, and rhinoliths. 

Microscopical Examination of the Nasal Secretion. The normal secre- 
tion from the nose contains squamous and ciliated epithelium, isolated 
leucocytes, and various fungi. The fluid is thick, alkaline in reaction, 

13 



194 



SPECIAL DIAGNOSIS. 



of slight odor. It contains mucin. In disease of the nasal cavities 
the fluid changes. In acute nasal catarrh it is more copious and thinner. 
It remains alkaline, and contains epithelium and fungi. When the 
stage of suppuration is reached, pus may almost entirely compose the 
secretion. Cerebro-spinal fluid may also be discharged through the nose 
in certain brain tumors. In such fluid albumin is absent. Detection 
of this fluid is of diagnostic value, pointing to the central lesion. 

In diphtheria the characteristic micro-organism is seen. Recognition 
of glanders may be based upon finding the bacillus in the nasal secre- 
tion (see Blood). Cultivations may be made. The nature of ulcers 
may be determined by microscopical examination. The tubercle bacillus 
can be detected at times. A pneumococcus has been found, or bodies that 
resemble it, in the secretion in ozsena. Thrush fungi have also been found, 
as well as some mould fungi. The Charcot- Ley den crystals are found 
in the nasal secretion in asthmatic patients, sometimes in acute coryza. 

Mouth-breathing. Much valuable information is obtained by noting 
the character of the breathing and the condition of the voice. Mouth- 
breathing is liable to be present if the face is drawn and vacant and 
there are cracks and fissures in the mouth. With mouth-breathing the 
voice is usually nasal. The resonating quality is lost entirely. Snoring 
accompanies these conditions, and they are all due to obstruction of the 
nares. (See Obstructive Symptoms.) 

Epistaxis. The blood may flow in drops, or a continuous stream 
pour out from the anterior nares. Sometimes it falls into the pharynx 
and is hawked up, or is swallowed and then vomited. 

It may occur from local causes, or be the result of constitutional con- 
ditions. Traumatisms (scratching the nose) new growths, and foreign 
bodies are causative agents. It may be due to fractured skull. Local 
causes : On inspection, the cause may be found in enlarged veins at the 
anterior inferior portion of the septum, a bleeding ulcer, a new growth, 
or the ulceration of a foreign body. The general conditions which are 
causal are : (1) Plethora; (2) engorgement due to the rising of an eleva- 
tion; (3) all forms of anaemia; (4) it is the common seat of bleeding 
in haemophilia ; (5) cerebral congestion and severe headache ; (6) in the 
commencement of fevers, and particularly typhoid fever, it frequently 
takes place. In children exposed to the sun, and after exertion, it is of 
frequent occurrence, and is seen often at puberty in delicate children. 

Disease of the Nose. 

Catarrhs of the Nose. These may be acute or chronic. 

Simple Acute Rhinitis. Acute Coryza, u Cold in the Head" 
Beginning with a feeling of lassitude, aching in the back and limbs and 
feverishness, a sense of fulness is felt in the nostrils, with sneezing. 
After twenty- four hours an irritating discharge from the nostrils begins. 
During this time the malaise has increased. The pain in the forehead and 
cheeks has become more pronounced, and a nasal twang is given to 
the voice. The feverishness continues, reaching 101° in the more pro- 
nounced cases, with thirst and loss of appetite. At the height of the 
fever, in forty-eight hours, very often a crop of herpes develops on the 



DISEASES OF THE NOSE AND LARYNX. 195 



lips. The general symptoms then subside and the local symptoms change. 
The discharge becomes thick and purulent, the fulness continues, but 
the pain is diminished. The inflammation has extended up the tear- 
ducts and to the eyelids. These are congested and may burn and be irri- 
tated. Very frequently, also, the inflammation extends to the pharynx, 
causing soreness of the throat and stiffness of the neck, and the larynx 
even may be involved. A slight deafness may arise from the inflam- 
mation extending into the Eustachian tube Rhinoscopic examination 
of the mucous membrane shows it to be red and swollen during the 
first day. The discharge, as described above, is secreted from it. The 
contractile tissue over the turbinated bones is congested and swollen, 
on account of which the nasal passages are occluded. To the probe 
the tissue is elastic, and it contracts promptly when cocaine is applied. 
The coryza may be symptomatic of measles, hay fever, or influenza. 

Fig. 23. 




Vertical section through nasal cavities. (Diagrammatic.) 
1. Superior turbinated bone. 2. Middle turbinated bone, with posterior hypertrophy. 3. Sec- 
tion of hypertrophied pharyngeal tonsil. 4. Inferior turbinated bone. 5. Orifice of Eustachian 
tube. (Seilee.) 

In the Diphtheritic Form of acute rhinitis the diagnostic symp- 
tom is the presence of the false membrane in the nose. If, during the 
presence of diphtheria, a sloughing coryza occurs and the cervical glands 
are found to be swollen, careful examination of the nose should be 
made. The discharge is very acrid in diphtheria, and is almost sure to 
cause excoriation of the upper lip, the presence of which condition 
under the above circumstances is of great significance. On rhinoscopic 
examination, a dirty-gray membrane is found lining the nostril. Bac- 
teriological examination confirms the diagnosis. 

Chronic Rhinitis. Four varieties may be distinguished, to all of 



196 



SPECIAL DIAGNOSIS. 



which the term nasal catarrh rnay be applied. In one there is hyper- 
trophy of the turbinated bones ; in the second, there is extension of 
the disease to the post- pharynx — chronic post-nasal catarrh ; in the 
third there is absolute dryness of the mucous membrane — rhinitis sicca, 
or dry catarrh ; in the fourth there is atrophy of the mucous membrane — 
atrophic rhinitis, or ozsena. 

In Chronic Hypertrophic Rhinitis, the affection comes on 
gradually after repeated acute attacks. The only symptoms may be 

Fig. 24. 






Rhinoscopic image from a case of posterior hypertrophy on the middle turbinated bone. (Seiler.) 

slight fulness in the nose and a little hoarseness of the voice. In more 
advanced stages, the symptoms of stenosis are marked, with oral breath- 
ing, snoring, and nasal sound. From the nostrils a constant discharge 
of muco-pus takes place, which is discharged backward into the pharynx, 
causing hawking. The hearing is frequently impaired, as well as the 
taste and smell. The discharge often affects the larynx, causing an 
irritating cough. The hypertrophied tissue on the turbinated bones, or 
pressure of the bone on the septum, may lead to reflex attacks of 
asthma. 

Rhinoscopic Examination. The uvula is thickened and elongated on 
account of the hawking. The outer surface or the edges of the turbinated 
bones are enlarged, either generally or in places. The mucous mem- 



DISEASES OF THE NOSE AND LARYNX. 



197 



brane covering these spots is thickened, hard, and rough. If cocaine 
is applied, the mucous membrane does not contract, as in the swelling 
due to hyperemia. The posterior ends of the inferior or middle tur- 
binated bones are enormously enlarged, forming round tumors which 
obstruct more or less the posterior nares and project into the pharynx ; 
polyps and deviation of the septum complicate these cases. 

Chronic Post-nasal Catarrh is an extension of the former into 
the pharynx. It is distinguished by discomfort or pain in the soft 
palate and posterior nares. There is tingling and a sense of fulness at 
the root of the nose, frontal headache is present, the patient complains 
of a bad taste in the back of the mouth and of constant flow of thick 
secretion into the pharynx, causing snoring and hawking. The same 
perversions of the sense of taste, smell, hearing, and of the voice occur 
as in acute rhinitis. In rhinoscojnc examination, in addition to the 
appearances in the nares, there is a mammillated appearance of the 
anterior wall and floor of the pharynx, with thickeniug of mucous mem- 
brane and posterior third of the septum. Headache seems to be due 
to the condition of the pharynx. 

Dry Catarrh, or Rhinitis Sicca, is also chronic in its course, 
accompanied with tingling and dryness of the nostrils. A faint, musty 
odor is detected, but there is no discharge or sense of obstruction. In 
severe cases there may be sharp pain in the nose extending to the fore- 
head. 

Rhinoscopic Examination. The mucous membrane is coated with dry 
mucus, while crusts form constantly, giving rise to much annoyance. 

Atrophic Rhinitis, or Ozjena, is attended by a sense of dryness 
in the nose. Occasional obstruction arises from accumulations of crusts, 
otherwise the passage is unduly open. There is constant hawking and 
spitting of brownish-green crusts which are often blood-tinged. Frontal 
headaches may occur in paroxysms. The spirits of the patient are often 
depressed. The odor is characteristic, and is diagnostic if syphilis is 
excluded. The bridge of the nose may fall in slightly. On rhinoscopic 
examination the mucous membrane is found to be thin, pale, hard to the 
touch, and covered with a layer of dried secretions and crusts. The 
nasal passages are abnormally wide and the turbinated bones very small. 
There may be hypertrophy in one nostril and atrophy in another. 

In addition to the above, a so-called Strumous Rhinorrhcea is 
seen in scrofulous children. There is a continuous discharge of rnuco- 
pus from the nostrils, which are obstructed by the swollen mucous 
membrane, and particularly by greenish-yellow crusts. 

Syphilitic Coryza is seen in infants and young children affected 
with hereditary syphilis. The discharge is at first thin and muco- 
purulent. It soon becomes thicker and more purulent, later thin and 
sanious. The nostrils are swollen and red at the edges, sometimes 
completely occluded, causing oral respiration and inability to take the 
breast or bottle. 

Pustules, fissures, and ulcers are found in the nose and at the margin 
of the orifices. They are also seen in the pharynx and larynx. Hemor- 
rhages may occur. Other evidences of hereditary syphilis are present. 

Rhinitis Caseosa has been described previously (see Secretion). 



198 



SPECIAL DIAGNOSIS. 



Nasal Polypi. 

On account of the presence of polyps in the nostrils there are symp- 
toms of stenosis. A sense of fulness and obstruction attended by oral 
breathing and snoring is common. An acute rhinitis or damp weather 
aggravates the symptoms. If neglected, conjunctivitis arises, on account 
of pressure on the lacrymal ducts. Epistaxis and sneezing are of fre- 
quent occurrence. 

Wiinoscopic Examination. The polypus is seen as a grayish-yellow 
or greenish shining mass projecting by a broad base from the mucous 
membrane. The probe shows that it is soft and yielding and that it 
can be circumscribed. 

Foreign Bodies. 

Animal parasites may find their way into the nostrils and act as 
foreign bodies, or substances may be thrust into the nostril. There is 
stenosis and secondary ulcerative rhinitis with foetid sanious discharge, 
often purulent. 

Rkinoscopic Examination. The foreign body may be seen at once or 
an ulcer only with granulating edges, be detected. The body is in the 
ulcer ; the probe, which must be used thoroughly, can usually detect it. 
Only in the tropical regions, usually, are parasites found in the nostrils. 
They are the larvse of the lucilia hominivora. It is said that the pain 
is so severe at the root of the nose, and thence extending backward, 
as to cause maniacal delirium. Sleeplessness is present, and there 
may be extensive destruction of the bones and skin. There is a foetid 
sanious discharge. Simple vegetable or inorganic bodies, as peas, beans, 
buttons, hair-pins, etc., cause pain which may become intense if the 
body is of vegetable origin and swells. 

Rhinoliths are foreign bodies in one sense, and yet they develop 
in the nostrils. They are gray or greenish-brown in color, hard and 
rough, either fixed or movable. They sometimes cause pain and reflex 
neuroses. 

Nasal Tumors. 

Tumors of the nose other than polypi partake of the same character- 
istics as tumors in other situations, and lead to symptoms of obstruction 
with internal and external deformity. In the beginning practically the 
symptoms are similar to those caused by a foreign body. Fibroma, 
sarcoma, osteoma, and enchondroma are seen. Malignant polypi or 
carcinomata grow rapidly. They extend over a large surface and are 
attended by pain. They bleed easily and cause a foetid, sanious, ichor- 
ous discharge. Epistaxis is common. Stenosis and deformity are 
marked. The glands of the neck are swollen. 

Glanders. 

This rare disease affects persons in contact with horses that have it. 
General symptoms consisting of pain in the trunk and limbs, with 
rigors followed by fever, occur first. Xausea and vomiting and diar- 



DISEASES OF THE NOSE AND LARYNX. 



199 



rhoea attend the first twenty-four hours of the attack. There may be 
dyspnoea. A typhoid type of fever is present. A pimple appears on 
the skin, which becomes painful and swollen, and at the same time a 
thick, yellowish discharge streaked with blood oozes from the nostrils. 
Hard pustules appear around the nose and in other parts of the body. 
Death occurs from exhaustion. (See Glanders, and The Blood.) 

Ulcerative Diseases of the Nose. 

We have to distinguish the syphilitic and tuberculous ulcer and the 
ulcer of lupus. In the former a history of infection, or of secondary 
and tertiary manifestations, can be obtained. The stench of the breath 
is sickening, and the patient complains of stenosis and loss of smell. 
There is some localized tenderness, and sleeplessness, debility, and 
emaciation may ensue. In tuberculosis, ulcers tend to bleed readily. 
They are usually secondary to tuberculosis in some other region of the 
respiratory tract. Microscopic examination of the scrapings from the 
ulcer reveal tubercle bacilli. 

If ozsena is present in a patient in whom lupus is seen on some 
part of the external surface, there is also probable lupus of the nasal 
passages. The ulcers may be followed by necrosis and caries of the 
bones. If the ozsena is not removable by antiseptic sprays the bones 
are probably affected. A discharge of sequestra makes the diagnosis 
positive. Rhinoscopy and careful palpation may reveal the ulcer and 
a carious bone. 

The Auxiliary Cavities of the Nose. 

The Antrum is subject to abscess, cysts and polypi, parasites, and 
tumors. 

Abscess. An odor somewhat like that of ozsena, a putrid taste, 
nausea, anorexia, pain in the cheek and root of the nose, often neuralgia 
in the frontal region, and malaise, are present. A very characteristic 
symptom is the discharge of pus from one nostril on leaning the head 
forward. There is often a bad tooth on the same side in the upper jaw. 

The Sinuses. The frontal, ethmoidal and sphenoidal sinuses are 
subject to inflammation, abscess, traumatism, and the irritation of for- 
eign bodies, usually parasites. 

The frontal sinuses are the only ones which exhibit external symp- 
toms. When these cavities are inflamed there are pain and tenderness 
over the frontal protuberances ; if the process goes on to the formation 
of abscess there maybe redness and swelling and finally fluctuation. If 
the communication is not closed there is a foetid discharge from the 
middle meatus. 

When the sphenoidal and ethmoidal sinuses are affected there are no 
external symptoms unless the enlargement is so great as to affect the 
orbit. There is deep-seated pain. Pus is seen exuding into the supe- 
rior meatus and flowing backward into the pharynx. Parasites cause 
intense pain and lead to abscess, caries, and necrosis. Rhinoscopic 
examination shows in disease of the antrum rough hypertrophic enlarge- 
ment on the under surface of the middle turbinated bone and a flow 



200 



SPECIAL DIAGNOSIS. 



of pus into the middle meatus. Sometimes a probe cau be passed into 
the antrum from the nose. Often an exploratory puncture is necessary. 
When the foramen is obstructed there is a dull aching pain in the upper 
jaw, with deformity of the orbit, face, hard palate, and nostril. Fluc- 
tuation can usually be found at some point after a time. 

The laerymal duct and sac are often the seat of inflammation by 
extension, on account of which there is pain, some obstruction in the 
nose, and epiphora. On examination pus will be seen flowing forward 
over the inferior meatus. By the laerymal probe the ducts are found 
to be painful and obstructed, and pus exudes. 

Reflex Neuroses. 

Bronchial Asthma. Asthma may be due to disease of the nose, but 
the only proof that it is of nasal origin is in its disappearance after 
treatment of the various faults in the nose, on account of which it may 
have developed. Hay fever is an acute affection ushered in by paroxys- 
mal sneezing, itching, and smarting of the inner canthus of each eye, or 
of the throat or nose. After hours or days of sneezing coryza develops. 
The disease continues for a varying length of time, is more pronounced 
at certain seasons of the year, particularly the late fall. Coughing 
may be an additional symptom, and paroxysms of asthma may develop 
which are hard to distinguish from true bronchial asthma. The attack 
may be excited by emanations from vegetation, particularly the pollen 
of plants, but other emanations may also induce it. The condition of 
the nasal mucous membrane predisposes to the attack. Local inflam- 
mation of the nose or obstructive disease from hypertrophies is pri- 
marily present. To the exciting cause and the local predisposing cause 
may also be added a neurotic factor. The disease affects families of 
nervous constitution, and may occur through several generations. It 
is more common in this country than in other countries, and dwellers 
in cities are more subject to it than residents in the country. 

Idiopathic Bhinorrhasa. Characterized by a sudden profuse dis- 
charge of yellowish water. It ceases as suddenly as it develops, and is 
thought to be due to some functional derangement of the fifth nerve. 

Diseases of the Larynx. 

The structural composition of the larynx does not differ from that of 
other parts of the respiratory passage. Mucous membrane, connective 
tissue, cartilages, and muscle are similar to these tissues elsewhere 
situated. 

The result of their anatomical association in the larynx is the estab- 
lishment of the functions of that organ, the formation of the voice and 
the passage of air into and out of the trachea. Now, the morbid pro- 
cesses that affect the larynx do not differ from the morbid processes 
elsewhere in which similar tissues are involved. Each tissue is liable 
to congestion, to inflammation, to degeneration, to new-growth forma- 
tion. The joints may become ankylosed, the muscles either paralyzed 
or the seat of spasm. The symptoms common to morbid processes in 
each class of tissue are seen. But other symptoms arise because of the 



DISEASES OF THE NOSE AND LARYNX. 



201 



anatomical position of the larynx and of its functions. The narrow 
chink of the glottis soon becomes occluded, and hence dyspnoea arises. 
Obstruction to the pathway or pain from inflammation or ulceration 
causes dysphagia. The sensitiveness of the mucous membrane provokes 
cough on the slightest provocation. The cords cannot vibrate or muscles 
and articulations cannot move, and dysphonia or aphonia occurs. 

The larynx is a highly specialized organ, and is well innervated. 
Large central nuclei, connected by a large nerve which passes over a 
circuitous route and which anastomoses with other nerve cords, pre- 
side over the function of phonation. Affections of the central nuclei, 
affections of the nerve trunk or of the structures adjacent, thereby 
pressing upon the trunk, have their expression in disorder of the larynx, 
and particularly if with disturbance of phonation. In other words, the 
phenomena of laryngeal disease may be symptomatic of disease of the 
brain or of the nerve trunk, as well as disease of the larynx. (See 
Nervous Diseases.) 

Because of its anatomical position and special function the symptoms 
of disease of the larynx are very striking, calling attention at once to 
their seat. Laryngeal affections are not liable to be mistaken for disease 
of contiguous parts, although retro- pharyngeal abscess, abscess at the side 
of the pharynx, disease of the thyroid gland, and inflammation of the 
lymphatics or cellular tissue in the neck may cause symptoms sugges- 
tive of laryngeal disease. 

Finally, morbid processes in the larynx determined by the symptoms 
and physical appearances may be symptomatic of general processes : 
acute inflammation, of erysipelas, typhoid fever, smallpox, or measles; 
chronic inflammation or ulceration, of the rheumatic or gouty diathesis, 
syphilis, or tuberculosis; scars, of syphilis; ankylosis, of rheumatic gout. 
The laryngeal symptoms of brain disease or of affections of the nerve 
trunk have been referred to. 

The practical point of all this is that affections of the larynx are not 
due to primary disease of that organ alone, but are often secondary to 
general processes or local morbid processes elsewhere. 

Therefore, when laryngeal symptoms or lesions are observed, seek 
beyond the larynx as well as in it, for their cause. 

The Data Obtained by Inquiry. 

Subjective Symptoms. Pain. Pain in the larynx may be sharp, 
stabbing in character, or simply a tickling or burning with a feeling 
of pressure. Pain is sometimes so intense as to render speaking and 
swallowing impossible. In acute laryngitis the pain is cutting and 
burning. In the milder inflammations, in dry catarrh, and in lupus it 
amounts to soreness only. The pain is severe and sharp in cases of 
cancer and tuberculosis, rarely in syphilis, and when foreign bodies are 
present in the structures. The pain may be very severe and intense 
when there is destructive ulceration. It is a diagnostic symptom of 
perichondritis. Usually the pain is localized in the larynx, but in 
ulceration it may extend to the ears. This is particularly true in car- 
cinoma. The pain is propagated by the auricular branches of the vagus. 



202 



SPECIAL DIAGNOSIS. 



Pain is increased by pressure in all affections of the larynx, and intensi- 
fied by the act of swallowing and by speaking. 

Paresthesia. Peculiar sensations are frequently complained of. 
They may be burning, tickling, or itching in character, or it may seem 
as if a foreign body were present in the part, as a hair, or it may seem 
like a draught of cold air striking the parts. Sometimes after a for- 
eign body has actually been present, the sensation of its presence will 
continue a long while after its removal. A sense of pressure or 
fulness, the feeling of a lump in the throat, is frequently com- 
plained of, provoking a desire to swallow. The patient will seek 
advice on account of it. It is known as the globus hystericus, and is 
recognized by the absence of local changes in the larynx, by its asso- 
ciation with other phenomena of hysteria, and by its disappearance 
or aggravation under the influence of excitement. This abnormal 
sensation is seen in hysteria and hypochondriasis. It is one of the 
nerve perturbations in chlorosis and anaemia. 

A feeling of dryness is frequently complained of, and attends the 
acute stage of acute laryngitis, and chronic laryngitis. The sense of 
fulness, or pressure, or feeling of the presence of a foreign body is com- 
plained of in all forms of laryngitis, in croup, in oedema of the glottis 
or epiglottis, and in syphilitic infiltration. 

Hyperesthesia and Anesthesia. When there is hyperesthesia there 
is constant desire to cough (see page 204), and the act is aroused on the 
slightest irritation. The desire to cough, independently of the act, how- 
ever, is of itself an extreme annoyance. It is a disagreeable sensation 
present in acute inflammations and in early phthisis. At times of men- 
struation and during pregnancy both symptoms are frequently com- 
plained of. Cough occurs reflexly in dentition. Hyperesthesia is easily 
recognized with the probe. In anesthesia particles of food fall into the 
larynx. The mucous membrane is insensitive to the contact of the 
sound. Anaesthesia occurs in hysteria, diphtheritic paralysis, paralysis 
of the superior laryngeal nerve, bulbar paralysis and cerebral softening 
or hemorrhage, or coma from any cause. 

Mis-swallowing, or " swallowing the wrong way," occurs in all condi- 
tions in which food is allowed to enter the larynx. Although con- 
ditions favorable for its occurrence are present it may not take place 
unless the patient is off guard during the act of swallowing, as when 
laughing is provoked. It may then occur even in normal cases. It 
is associated with anaesthesia of the larynx, and occurs in central nerve 
affections which cause that condition. 

Dyspnea. This is one of the frequent symptoms — and the most 
serious — of laryngeal disease. It occurs when obstruction takes place, 
and may be due to spasm, to inflammatory or oedematous swelling of 
the tissues of and about the larynx, to tumors or foreign bodies in the 
larynx, to the cicatrization of ulcers after syphilis or lupus, to paralysis 
of the abductors or adductors of the larynx. Disease of surrounding 
structures which press upon the larynx causes dyspnoea, which is 
similar to that due to actual disease of the organ. 

Dyspnoea may vary iu degree from slight inconvenience in breathing, 
only felt by the patient, to the violent struggling for breath which is 



DISEASES OF THE NOSE AND LARYNX. 



203 



seen in cases of extreme stenosis of the larynx. If carefully observed 
in either case the larynx is seen to rise and fall. If the obstruction 
is present in its more aggravated form the head is bent back, the neck 
stretched, the muscles of the neck contracted. The spaces above the 
sternum and at the sides of the trachea are drawn in with inspiration, and 
the alse of the nose work vigorously. Further evidence that sufficient 
air does not enter the lungs is seen in the recession of the epigastrium 
and the drawing in of the ribs at the base of the chest during the act 
of inspiration. At the same time the countenance is dusky or ashy- 
gray, the lips become cyanosed and the nails bluish as the dyspnoea 
persists and deepens. A cold perspiration breaks out on the forehead, 
and finally, from exhaustion, the respiration becomes slower and slower 
until mere gasps are seen. The heart's action increases in frequency as 
the stenosis increases. Death usually takes place from asphyxia, the 
child first falling into a stupor on account of carbonic acid poisoning. 
The dyspnoea under these circumstances in the various degrees de- 
scribed is generally inspiratory. Noise attends the act of inspiration, 
the character of the sound depending on the nature of the obstruction. 
If the obstruction arises from simple spasm, or from intense inflamma- 
tion of the larynx, without secretion, the sound of inspiration is harsh 
and stridulous. In obstruction that occurs from oedema or from 
exudation, as in laryngeal diphtheria, the sound of inspiration is loud 
and stridulous but not shrill. The expiration is usually noiseless and 
prolonged. The short, stridulous, or gasping inspiration is followed 
by prolonged gentle expiration. In spasmodic croup, the expiration 
is like snoring. The interval between expiration and inspiration is 
lessened, the respirations are hurried. 

In another form of dyspnoea the obstruction takes place when the air 
is passing out of the lungs, as in eases of a movable tumor below the 
vocal cords. The act of inspiration is complete, the act of expiration 
is suddenly checked by the obstruction, on account of which the lungs 
become overfilled with air, and an emphysema develops. In another 
variety, laryngismus stridulus, the act of breathing ceases in the midst 
of inspiration. Cyanosis develops (see Color, page 72). 

The dyspnoea from disease of the larynx may develop gradually and 
continue over a long period of time, or it may be acute in onset, depend- 
ing upon the character of the morbid process on account of which the 
obstruction has taken place, Acute paroxysms of dyspnoea, in one of 
which a fatal ending may take place, are liable to occur in the course 
of affections in which chronic dyspnoea is present ; thus sudden oedema 
may occur in cases of syphilitic or tuberculous ulceration. 

Laryngeal dyspnoea must be distinguished from other forms of dys- 
pnoea. This has been considered elsewhere with regard to the dyspnoea 
due to diseases of the heart and lungs. 1. The dyspnoea that occurs on 
account of pressure upon the trachea differs. The larynx is not 
markedly moved during the respiratory acts, and the patient bends the 
head forward instead of backward. 2. The diseases which cause dys- 
pnoea from pressure on the larynx must be excluded. Cellulitis of the 
neck, tumors of the lymph glands, goitre and retro-pharyngeal abscess 
are provocative of this form of laryngeal dyspnoea. Examination of the 



204 



SPECIAL DIAGNOSIS. 



respective localities by inspection and by touch reveals the cause. It 
may be worthy ol remark that dyspnoea in diphtheria, frequently 
thought to be due to internal occlusion, may be due to pressure of en- 
larged glands on the bronchus and larynx. 

Dysphagia. Difficulty of swallowing is most marked when destruc- 
tion of tissue in the larynx takes place, or when there is acute inflam- 
mation about the muscles or their attachments; hence, when ulcers, 
tuberculous or malignant, are present, or perichondritis arises, the diffi- 
culty is so great with the pain that arises as to prevent the taking of 
food. When the epiglottis is the seat of acute inflammation there is 
great dysphagia on account of pain, or perhaps on account of the 
obstruction. When the epiglottis is fixed, and in forms of ulceration 
of the larynx, particularly if that structure is involved, the food enters 
the larynx, and hence dysphagia is produced. 

Dysphagia is recognized by pain and by the falling of particles of 
food into the larynx, exciting cough. It must be distinguished from 
the dysphagia of pharyngeal affections by ocular examination, the 
location of pain, and the non-association of rheumatism. 

Dysphonia. The most common symptom of affections of the larynx 
is disturbance of the function of speech. The voice is changed in 
character, or may be lost in any affection which causes swelling of the 
mucous membrane, or occlusion of the orifice, or which interferes with 
the action of the vocal cords. The voice may be hoarse in acute and 
chronic inflammations, in tumors and in specific ulcerations about the 
larynx, and in paralyses of the cords. From simple hoarseness it may 
vary in intensity to complete aphonia. The laryngoscopic examination 
is necessary in order to detect the presence or absence of paralyses. 
(See Paralyses.) 

The character of the voice may change. When one-sided paralysis 
of a cord is present the voice is flat and toneless. In cases of paresis 
of the tensors of the cords a falsetto voice is created. Diplophonia 
occurs in one-sided paralysis, and in some cases in which small tumors 
lying between the cords come up during the act of phonation and form 
nodes. Two tones are formed at the same time in this class of cases. 
Frequently only certain tones are doubled. The duration may be sig- 
nificant. Hoarseness of long duration (years) is said to be prodromal 
of cancer. (Ziemssen.) 

Functional dysphonia or aphonia may occur after excessive use of the 
voice and in hysteria. Hysterical aphonia occurs in women and young 
girls ; the laryngoscope reveals nothing ; the acts of coughing and 
sneezing are normal, and a sound may be created in either ; it occurs or 
disappears suddenly. 

Cough. (See Diseases of the Lungs.) Sometimes valuable informa- 
tion is derived from the character and severity of the cough. Several 
forms are noted : 

First, the dry cough, as seen in acute laryngitis. It is almost constant, 
and is aggravated when the patient speaks, takes fluid, or inspires 
deeply. In children it is abrupt, brassy or metallic, stridulous or 
whistling, so-called " croup cough," as seen in cases of " false croup" 
and laryngitis with oedema. 



DISEASES OF THE NOSE AND LARYNX. 



205 



Second, a dry hoarse cough occurs in the course of chronic laryngitis. 

Third, cough with whoop. With the act of coughing a whooping 
souud may be heard in inspiration. After rapid violent expiratory acts 
with inspiration, the whoop takes place. It is spasmodic aud convul- 
sive, aud is followed by retching, and often by vomiting. 

Fourth, the cough is of such a character as to give one the idea that 
it is suppressed, in membranous and cedematous laryngitis. 

Fifth, a cough frequently occurs without any local anatomical changes 
in the larynx, which seems to be purely of nervous origin. Two forms 
are seen : a. Paroxysmal form. Severe coughing occurs suddenly, 
and cannot be controlled by the patient. It ceases without cause, 
returning in a few hours. There is no expectoration, b. It may be 
continued and rhythmical in character. It is not so severe as in the 
paroxysmal form, but consists in a regularly recurring cough more or 
less loud. It does not occur while eating or speaking and ceases 
entirely during sleep. It is usually worse when the patient is under 
observation. Examination with the laryngoscope reveals absence of 
disease. This form of cough is seen after diphtheria, when sexual dis- 
turbances are present, at puberty, in cases of anaemia and chlorosis, or 
of neurasthenia or hysteria. The tone is usually high. 

Hemorrhages. Hard coughing or an unusual straining of the voice 
may lead to the occurrence of slight hemorrhage. Only after injuries 
are hemorrhages from the larynx at all copious. Moderate hemorrhages 
occur in scurvy, haemophilia, hemorrhagic smallpox, typhus fever, and 
leukaemia. 

Disturbance of Co-ordination. Several forms of such disturbance are 
seen. Spasm of the glottis may occur with each effort to speak, causing 
either serious interference or complete inability to utter a word, as in 
stuttering. Sometimes, instead of the glottis opening to complete the 
act of inspiration, it may close. Sudden inspiratory dyspnoea, there- 
fore, occurs, and is attended with stridor. 

General Symptoms. In the study of laryngeal affections it is well to 
note objective phenomena distant from the organ or of a general character. 

1 . Fever, present in acute laryngitis and tuberculous ulceration. It is 
high in acute laryngitis with stenosis ; in tuberculosis it is of a hectic 
type. 

2. Cyanosis or cyanosis aud pallor in laryngeal stenosis. 

3. Extended and dilating alas nasi in severe stenosis. Recession at 
the sternal notch and above the clavicles, and at the base of the thorax. 

4. Cold sweating, sudden, with pallor, in laryngeal obstruction, as 
laryngismus stridulus, or when a foreign body is present. 

The Data Obtained by Observation. 

Objective Symptoms. The objective symptoms are determined 
by inspection and palpation. Inspection of the exterior of the larynx 
reveals the presence of swelling, and the movements of the organ as a 
whole. Local swelling of the tissues over the larynx may occur in 
inflammations of the cartilages ; they are usually of syphilitic origin, 
but may attend carcinoma or follow tumor. There is more or less 



206 



SPECIAL DIAGNOSIS. 



marked swelling in inflammation of the cartilages, which after a time 
fluctuates, and when opened discharges pus and necrosed cartilage. 
The objective signs of inflammation are noted. 

The movement of the larynx is increased in cases of dyspnoea. It is 
accompanied by recession of the spaces above the sternum and the clavi- 
cles, with clonic contraction of the sterno-cleido-mastoid muscle. 

The interior of the larynx is studied by inspection (laryngoscopy), 
aud by palpation (probe or fingers). 



Fig. 26. 




Laryngeal mirror in position, displaying the laryngeal image. (Cohen.) 

Laryngoscopy. In order to conduct laryngoscopy it is necessary 
first to have a good light. This may be direct sunlight, a good stu- 
dent's-lamp, or an Argand gas-burner. Electricity is not satisfactory. 
Second, a good reflector is required. It may be attached to a head-band 
or a spectacle-frame. It should be concave for artificial light, plain for 
sunlight, and should be pierced in the centre. Third, laryngeal mirrors 
of different sizes and a curved probe complete the instruments necessary 
for examination of the larynx. 



DISEASES OF THE NOSE AND LARYNX. 



207 



Examination. The patient is seated with the source of light at one 
side and behind him; the head and shoulders are brought well forward 
and the head slightly raised. The operator takes a seat in front of the 
patient at a proper distance for the focal leugth of the reflector, and 
focusses the light on the patient's mouth, warms the laryngeal mirror 
over the flame and tests its temperature on the back of the hand. It 
should be raised to a moderate warmth, in order that when placed in 
the mouth the vapor of the breath may not precipitate on its surface. 
The patient must open the mouth and protrude the tongue, which is 
grasped between the folds of a napkin by the thumb and fingers of the 
operator. The tongue should be gently but firmly grasped. The mirror 
is then inserted carefully and quickly, face downward, into the pharynx. 
Care must be exercised not to touch the tongue or palate, otherwise the 
patient may be made to retch and he becomes alarmed. The mirror 
is passed to the posterior wail of the pharynx, and so directed that the 
image of the larynx is reflected to the eye of the operator. The patient 
is made to phonate " a" or u ee," not "ah," and then to respire. The 
various structures and the action of the cords are observed. The appear- 
ances of the mucous membrane are studied during quiet respiration. 

The epiglottis is very dependent, so that often the larynx can only 
be seen by having the patient stand while the operator remains seated. 
The patient's head is bowed on his chest and the examination proceeds. 

The first examination may not result satisfactorily, but little being 
observed on account of the spasm of the pharyngeal muscles. Repeated 
sittings may remove apprehension and accustom the mucous membrane 
to the presence of the instrument. This object may be attained by 
administering the bromides, or by applying cocaine to the pharynx. 

The probe is needed only to ascertain the consistency of tumors and 
growths. Cocaine must be applied before it is used. 

Sputum. The sputum from the larynx is generally scanty ; it is 
not frothy, and is colorless and transparent ; it is often discharged in 
small globules ; it may be streaked with blood. Sometimes pseudo- 
membranes are coughed up. It is doubtful if purulent sputum ever 
comes from the larynx, excepting in cases of perichondritis in which the 
abscess bursts into the larynx. Laryngeal sputum is found in catarrhs 
and maliguant tumors. It is blood-streaked when the catarrh is very 
intense, or after injuries. 



Fig. 27. Fig. 28. 




Laryngeal image during respiration. Laryngeal image during phonation. 



Appearance of the Larynx in Health. Fig. 26 shows 
the larynx as it is seen in the laryngoscopic mirror. Above (upper 
part) is the arched epiglottis, below it the cavity of the larynx. In 
the centre are the vocal cords, white and glistening ; on each side of 



208 



SPECIAL DIAGNOSIS. 



these the pink folds of the false cords. At the bottom of the mirror 
are the arytenoid bodies, and between them the folds of the inter- 
arytenoicl space. Below and outside of the arytenoid bodies are the 
fossae. The mucous membrane is pink throughout except on the cords. 
In respiration the arytenoids separate, carrying the ends of the cords 
which are attached to them with them, and leaving a triangular open- 
ing — the glottis — through which the rings of the trachea can be seen. 
(Fig. 27). In phonation the arytenoids approach each other, obliterat- 
ing the inter-arytenoid space; the inner edges of the cords come in con- 
tact and close the glottis. (Fig. 28.) The appearances in disease are 
described under the different diseases. A note must be made of the 
color of the various parts, of the presence or absence of swelling or 
ulceration, and of the movements of the parts concerned in phonation. 
The latter particularly applies to the movements of the cartilage and of 
the cords, a full discussion of which will be found under Laryngeal 
Paralyses. Two conditions seen by the laryngoscope, common to many 
laryngeal disorders, will be spoken of in this place : 

Anosmia of the larnyx may be merely a part of a general anaemia 
from any cause. In chlorosis it is seen before the external appearance 
is marked. An intense anaemia of the larynx is an early and valuable 
symptom of pulmonary tuberculosis. The mucous membrane is pale. 

Hypercemia may be active or passive. It is readily recognized by 
the intense redness. 

Active hyperemia occurs with overstrain of the larynx (very frequent 
and often constant in bass and baritone singers); with irritation from 
foreign particles, as in " swallowing the wrong way ;" inhalation of hot 
or irritating gases or vapors ; in the early stage of inflammations, syphi- 
litic infiltrations, or ulcerations. 

Passive hyperaemia occurs in general obstruction to the circulation, as 
emphysema or valvular lesions ; pressure on veins by tumors; forced ex- 
piration and holding the breath ; in paroxysmal cough, especially whoop- 
ing-cough. Active hyperemias lead to catarrhs, passive to oedema. 

Acute Laryngitis. Acute laryngitis is an inflammation of the 
larynx, characterized by a sensation of fulness and dryness in the larynx, 
with cough, hoarseness, and at times dyspnoea. Several varieties are 
observed : simple acute laryngitis, laryngitis with great stenosis, 
laryngitis with membrane, laryngitis with spasm. 

It is caused by exposure to cold or by the inhalation of acrid vapors. 
Excessive use of the voice, particularly in a cold air, may excite an 
attack. It may be symptomatic of the eruptive fevers, as measles or 
smallpox, or erysipelas. Its occurrence in the course of chronic dis- 
eases must be looked upon with alarm, particularly in cases of Bright's 
disease, if dropsy is present in other situations. 

The attack begins with a feeling of chilliness, followed by fever of 
varying degree, but usually mild. A feeling of pressure and dryness 
in the larynx, or as if a foreign body were present is complained of. 
Some pain gradually develops in the height of the attack, never so 
severe as to require an anodyne. From the first there is cough. It is 
dry and hacking, and slightly painful. In the more intense forms the 



DISEASES OF THE NOSE AND LARYNX. 



209 



cough is continuous, disturbing the patient by night and day. Paroxysms 
occur when the patient speaks or takes food. First the cough is dry ; 
within a short time it becomes moist, and expectoration of a clear, 
transparent mucus takes place. The mucus may be tinged with blood. 
At the end of forty-eight hours expectoration grows more yellowish 
and opaque. The voice may be merely hoarse, or may be lost entirely. 
Sometimes aphonia without general symptoms occurs in acute laryngitis. 
In laryngitis sicca cough and dyspnoea occur in paroxysms and are not 
relieved until a dry secretion is coughed up. The paroxysms take 
place at night or in the early morning, and may cause retching and 
vomiting. It is seen in adults. 

Acute Laryngitis with Stenosis. No doubt some of the cases of 
so-called membranous croup that we see in children are cases of acute 
laryngitis, with swelling and occlusion of the glottis by congestion and 
by tough secretion. CEdema may or may not be present. The attack 
begins with catarrhal symptoms. The child is languid, refuses to eat, 
has thirst, and some chilliness and rise of temperature. With the 
slight cough, which may be shrill, there is hoarseness and some difficulty 
in breathing, but no pain on swallowing. On the second day, or after 
the lapse of four or five days, during which time mild fever continues, 
the catarrhal symptoms become more marked. The voice is more hoarse 
or may be suppressed. The harsh, clanging cough becomes toneless, and 
soon the sound is suppressed. The respirations are hurried, and dyspnoea 
is most severe. They are noisy, attended by loud whistling inspiration, 
snoring expiration. The stenosis is inspiratory, and during the day or 
in the succeeding twenty-four hours may become very intense. It is 
attended with violent efforts at breathing and the occurrence of cyanosis 
in its most aggravated form. The larynx moves up and down, the head 
is thrown back. There is recession at the root of the neck and along the 
margins of the ribs and the epigastrium. The lower portion of the 
sternum may be drawn in. Duskiness of the extremities and of the 
lips is observed as the stenosis becomes more marked, finally deepening 
into cyanosis. It may be relieved from time to time by removal of the 
obstruction, which occurs after cough, vomiting, or change of position. 
A paroxysm soon recurs. With each paroxysm lividity becomes more 
and more marked, the respirations continue hurried. The face becomes 
pale, the extremities cold, and a cold sweat bathes the brow. Rest- 
lessness is characteristic. The child tosses about in the bed or from the 
bed to the arms of the nurse. The heart's action is increased each hour 
in frequency as the stenosis advances, and becomes weaker. As exhaus- 
tion ensues and the symptoms of obstruction become more marked, 
stupor deepening into unconsciousness develops. Convulsions may 
occur at the end. The attacks rarely recur if once recovered from. 
They follow exposure to cold. 

If recovery takes place, the child usually becomes more free from 
dyspnoea, the cyanosis fades, and the restlessness disappears. A pro- 
longed sleep attends the relief, although the voice may remain hoarse or 
suppressed, and the cough continue many days. 

Laryngeal Diphtheria. The same symptoms are seen in 
cases of membranous croup or laryngeal diphtheria. In the latter 

14 



210 



SPECIAL DIAGNOSIS. 



affection there may be a history of exposure or of infection. With the 
commencement of the attack the patches of diphtheria may be seen in the 
fauces or nares. If membrane can be secured and a bacteriological 
examination made, the diagnosis of diphtheria with stenosis is positive ; 
enlarged glands in the neck, with more marked depression, a moderate 
degree or absence of fever, and occurrence of early albuminuria, also 
point to diphtheria. The distinction of the two affections is nevertheless 
quite difficult, and as long as there is a shadow of doubt, for prophy- 
lactic reasons the case should be considered one of diphtheria. 

Acute Laryngitis, with Spasm. False Croup or Spasmodic 
Laryngitis. In children, in addition to mild and intense forms of 
laryngitis, a form is frequently seen associated with spasm of the 
larynx. The catarrhal symptoms are mild, so that the child seems to 
be well during the day. Fever is absent and a slight cough or huski- 
ness alone calls attention to the larynx. After the first three or four 
hours of quiet sleep the child suddenly awakens with a barking cough, 
sits up and struggles for breath on account of suffocation. The dyspnoea 
continues for a few minutes to an hour or so, gradually lessening, to 
disappear entirely as the child lapses into sleep. Throughout the next 
day the child seems well as on the previous day, and the succeeding 
night is seized with another attack of " croup." This may occur once 
or twice during the night. It seems to be influenced by the w T eather, 
Damp days and an east wind are provocative of the attack. It recurs 
frequently during the same season. 

Laryngoscopic examination reveals the characteristic appearances seen 
in cases of acute laryngitis. In children, in whom the disease frequently 
occurs, such examination cannot well be made. 

Inflammation or the Epiglottis. The epiglottis may be inflamed 
in cases of laryngitis, or become so independently. The sensation of a 
lump in the throat at the base of the tougue or the top of the larynx 
is complained of, and pain in attempting to swallow occurs. The pain 
becomes very intense at times. Fluids cannot be taken, for when the 
patient attempts to swallow, because the epiglottis does not protect the 
glottis, the fluid enters. The voice is usually clear throughout the 
attack, and the general symptoms are not marked. 

On laryngoscopic examination the epiglottis is seen as a thick, red 
tumor. It may be felt by the finger. 

(Edema of the Larynx. This condition arises in the course of acute 
laryngitis, frequently occurs in chronic diseases of the larynx, particu- 
larly if ulceration is present, and is a complication of erysipelas and 
diphtheria. In some cases of Bright' s disease it may develop suddenly. 

In the course of the above-mentioned disease the onset of the symp- 
toms of laryngeal stenosis may occur suddenly. The voice becomes 
husky and suppressed, the dyspnoea is very extreme, so that in a few 
hours grave symptoms of obstruction arise. There is no cough. The 
patient complains of the sensation of a foreign body and tries to grasp it. 

On laryngoscopic examination the epiglottis and arvteno-epiglottidean 
folds are swollen. The epiglottis can usually be felt by the finger. If 
so it is of diagnostic importance. 



DISEASES OF THE NOSE AND LARYNX. 



211 



The Diagnosis of Acute Diseases of the Larynx. 

Acute affections of the larynx are distinguished from other diseases 
without much difficulty. To recognize the various forms of acute 
laryngitis, however, is not so easy. In all there is laryngeal stenosis to 
a certain degree, and practically the question to answer is, Which form 
of stenosis is present ? The accompanying table shows the differential 
points for diagnosis. It is seen that the age, occurrence of previous 
attacks, the character of the general symptoms, the existence of previous 
laryngeal disease, the association of faucial disease, the presence or 
absence of membrane, and the results of laryngoscopic examination 
must be considered before making a positive diagnosis. 



Simple Acute Laryngitis.— ■" Catarrh of Larynx." 

Gradual onset of laryngitis, with dyspnoea very 

slight or absent. 
All ages. 

Fever of varying degree. 
Dry irritating cough. 
May he hoarseness. 
Pharynx reddened. 
Gradual increase and decline. 

Larynx red and slightly swollen, as seen by 
laryngoscope. 

Acute Laryngitis with Spasm.— Spasmodic Croup. 

May be slight hoarseness or cough, or none. Sud- 
denly in night, child wakes with intense 
dyspnoea and crowing inspiration. 

Children. 

Temporary high fever. 
Slight brassy cough during day. 
May be slight hoarseness in day. Very hoarse 
in attack. 

Lasts a few minutes to one hour. May recur or 

no attack until next night. 
Slight redness, or nothing seen by laryngoscope. 

(Edema of Larynx. 

Some inflammatory disease of larynx exists. 
Rapid development of dyspnoea, increasing to 
great severity. 



All ages. 

Depends on cause. 
No cough. 
No hoarseness. 



Increases steadily to climax, then death or de- 
cline of dyspnoea. 

Epiglottis and aryteno-epiglottic folds swollen, 
pale, and waxy. 

Foreign Bodies. 

During eating or while holding object in mouth 
sudden dyspnoea, varying in intensity accord- 
ing to object. 

All ages. 
No fever. 

Irritative, expulsive cough. 
May be hoarseness or not. 



Cough persists till removal of body, or occasion- 
ally the larynx becomes accustomed to its 
presence, and cough ceases. 

See the foreign body. 



Acute Laryngitis with Stenosis. 

Gradual onset of laryngitis, but dyspnoea de- 
velops to great severity. 
Children. 

Fever of varying degree. 

Dry cough, often paroxysmal. 

Hoarseness. 

Pharynx reddened. 

Gradual increase, and either death of patient or 

decline of dyspnoea. 
Same, but swelling much greater. 



Laryngismus Stridulus. — " Child-crowing." 

No laryngitis. Sudden attacks of dyspnoea with 
crowing inspiration, either day or night. Very 
severe. May be general convulsions. 

Children or hysterical adults. 

No fever. 

No cough. 

No hoarseness. 

Occurs often in rhachitic and hysterical cases. 
Ends suddenly, in at most two minutes, and 

occurs often. 
Nothing seen in larynx. 

Membranous Laryngitis. — Croup ; Diphtheria. 
Epidemic. 

Gradually developing hoarseness and croupy 
cough, with low fever and lassitude, then de- 
velopment of dyspnoea, gradually and without 
intermission, as a rule. 

Children. 

Low fever and depression. 
Croupy cough, later suppressed. 
Very hoarse. 

Fauces red and often with membrane ; albumin- 
uria ; paralyses. 

Increases steadily, broken by intense paroxysms. 
Either death or gradual improvement. 

Red, swollen, and membrane. 



Pertussis. — Whooping-cough. 

Epidemic. 

Bronchitis, with cough developing from one to 
three weeks. Then dyspnoea caused by severe 
paroxysms of coughing — absent between them. 

Children. 

Only the fever due to bronchitis. 
Intense paroxysms of coughing. 
No hoarseness. 

Hemorrhages in various places from strain or 
emphysema. 

May be death from exhaustion, or gradual im- 
provement. 

Nothing seen, unless slight laryngitis. 



212 



SPECIAL DIAGNOSIS. 



Chronic Laryngitis. 

Chronic laryngitis either originates in an acute attack or comes on 
slowly, Prolouged use of the voice in a higher key than natural or in 
the open air, the use of alcohol, constant exposure, are exciting causes. 
It is symptomatic of syphilis and tuberculosis. It frequently results 
from inflammation of the upper air-passages, particularly chronic 
pharyngitis. It occurs after middle life more frequently, and usually in 
the male sex. There is discomfort on long speaking, with dryness and 
tickling. At first the secretion of mucus is very slight, but after hawk- 
ing and coughing, it increases in amount. Hoarseness occurs, and if 
the patient is careless or persistent in the baneful occupation, complete 
aphonia may arise. The voice is clearest in the morning, after expec- 
toration of the mucus that accumulated in the night, but becomes husky 
toward night. The aphonia may occur in paroxysms, relieved by 
coughing up of dry secretion. The cough is never severe. The sputum 
is small in amount, glairy, and often in little balls or crusts. 

Laryngoscopic Examination. Hypersemia and swelling of varying 
degree of the epiglottis, the outer arytenoid space, and the false cords 
are seen. The cords may be uneven, or granular from nodes. Fine 
threads of secretion, or little balls of mucus, may also collect. Fissures 
or erosions are seen on the cords and in the folds. In the dry form of 
chronic laryngitis, the mucous membrane is pale and thin, and crusts 
form. 

Acute Submucous Laryngitis. 

The inflammation extends to the submucous cellular tissue. It arises 
in the course of acute laryngitis, and is the form seen in traumatism, or 
from burns and scalds. The symptoms are those of intense laryngitis 
with stridor. They increase in severity until stenosis arises. If the 
under surface of the cords is affected, death will occur from asphyxia. 
Sometimes the inflammation is circumscribed and followed by develop- 
ment of an abscess. 

On laryngeal inspection the diffuse form cannot be distinguished from 
ordinary laryngitis. The circumscribed form is recognized by a swell- 
ing on the top of which the yellow point, due to the suppuration, grad- 
ually appears. In the hypoglottic form, or so-called osdema of the 
glottis, a round, fixed swelling is seen on each side below the vocal 
cord, almost entirely occluding the larynx. 

The chronic form of submucous inflammation of the larynx is usually 
seen in drunkards, and is recognized usually by the laryngoscopic ex- 
amination. The symptoms are those of slight stenosis. On inspection 
a dirty-red diffused or circumscribed swelling of some part of the 
larynx is observed. It may be seen on the epiglottis, or the aryteno- 
epiglottic folds below the cords. 

Phlegmonous Laryngitis or Perichondritis. 

Inflammation about the cartilages is usually phlegmonous in charac- 
ter, and leads to the formation of abscess. The collateral oedema is so 



DISEASES OF THE NOSE AND LARYNX. 



213 



great as to cause some obstruction, with cough and hoarseness. On 
palpation, the larynx is extremely tender. The pain is increased by 
movement of the larynx, and occurs in speaking or swallowing. If 
the inflammation involves the arytenoid cartilages, pain extends toward 
the ear, the vestibule is swollen, the cartilage fixed. On the other 
hand, when the cricoid is diseased, there is pain on swallowing of solid 
food on account of interference with the muscular attachments, dys- 
pnoea, and paralysis of the posterior crico-arytenoid muscles. Inflam- 
mation of the thyroid cartilage may open externally or internally. In 
the latter case the abscess can be seen in the larynx. 

An examination by the laryngoscope shows swelling or oedema so 
great that the parts cannot be well outlined. Discharge of pus and 
necrosed cartilage confirms the diagnosis. By means of a sound the 
cartilage can be detected, giving further proof of the presence of the 
disease. 

Neuroses of the Larynx. — Laryngismus Stridulus. 

Laryngismus Stridulus, or spasm of the glottis, is seen usually in 
children that are poorly nourished. It is of frequent occurrence in rickets, 
indeed its occurrence points very strongly to the possibility of that dis- 
ease being present in children in whom otherwise the manifestations 
are obscure. 

The symptoms occur suddenly, and are very alarming. The child 
awakens in the night, and after a few short whistling inspirations, sud- 
den cessation of breathing takes place. The child is seized with terror, 
which is depicted on the countenance ; the eyes stare, the face is pallid at 
first, but rapidly becomes livid. The alae nasi are extended, the head 
is thrown back, and the spine arched. A cold perspiration breaks out 
over the forehead. Carpo-pedal spasms may occur and the urine and 
faeces be discharged involuntarily. After a period varying from a few 
seconds to at the furthest two minutes, the child draws two or more 
deep, noisy inspirations, each one lessening in depth and sound, when 
color returns to the face, the cyauosis gradually disappears, and the 
child becomes tranquil. 

In mild forms the child " catches its breath." It holds its breath, 
and then makes a noisy inspiration. 

The attacks of laryngismus stridulus are more rare in adults. They 
may occur in hysterical subjects. In the attack there occurs a series of 
long, harsh, whistling or stridulous inspirations, followed by short, 
noisy expirations. Rarely is there complete closure of the glottis. 

In both children and adults general convulsions may occur during 
the attack, or carpo-pedal spasms alone may be seen. In adults the 
convulsions occur only in hysterical subjects. 

Spasm of the glottis is a frequent complication of diseases of the 
larynx. It is due to peripheral irritation in the idiopathic form. 

The diagnosis of laryngismus stridulus is based upon the absence of 
laryngeal symptoms prior to the attack, the absence of cough or hoarse- 
ness, and the complete disappearance of all laryngeal symptoms when 
the attack subsides. The absence of pain and fever and of laryngo- 



214 



SPECIAL DIAGNOSIS. 



scopic signs is noteworthy. This applies, of course, to spasm that 
occurs independently of laryngeal disease. 

Paralyses of the Laryngeal Muscles. 

They are divided for convenience into groups. The symptom is dys- 
phonia, which, with laryngoscopic appearances, leads to the recognition 
of the paralysis. 

1. Paralysis of the Tensors of the Cords. The cri co-thyroid 
muscle is paralyzed ; the superior laryngeal nerve, which supplies the 
muscle is concerned. The voice is deep and rough, and incapable of 
producing high tones. Usually, the whole nerve is involved, and the 
result is ancesthesia of the larynx and jiaralysis of the epiglottis also. 

Laryngeal Examination. The epiglottis is fixed and back against the 
the tongue. The glottis opening is a wavy line. 

Causal disease. The condition described occurs almost exclusively 
after diphtheria. 

2. Paralysis of the Closers of the Glottis, or Adductors 
of the Cords. The muscles involved are the crico-arytenoideus 
lateralis, arytenoideus transversus, and the thyro-arytenoidei internus 
and externus. The nerve is the recurrent laryngeal. 

The symptoms are complete aphonia, coming suddenly, and often as 
suddenly going. 

Laryngeal Examination. During phonation the cords remain in the 
inspiratory position. The paralysis may affect one or both sides. 



Fig. 29. Fig. 30. 




Paralysis of the arytenoideus transversus in Paralysis of the thyro-arytenoideus internus 

phonation. (Gottstein.) in phonation. (Gottstein.) 

Sometimes the arytenoideus transversus alone may be affected. Then 
there is hoarseness or aphonia. The anterior portions of the cords come 
together in phonation, but the posterior portions do not, leaving a 
triangular opening posteriorly. (See Fig. 29.) 

Or, the thyro-arytenoideus internus may alone be affected. There is 
then dysphonia or aphonia, as before, but the cords come together at 
both extremities and remain apart in the middle, forming an oval 
opening. (See Fig. 30.) 

Causal disease. These paralyses occur in hysteria, catarrh, or severe 
overstrain of the voice. 

3. Paralysis of the Openers of the Glottis, or Abduc- 
tors of tpie Cords. The muscle affected is the crico-arytenoideus 
posticus, and the nerve is the recurrent laryngeal. 



DISEASES OF THE NOSE AND LARYNX. 215 

Symptoms. When one side is affected the respiration is free, but 
there is stridor on forced inspiration. The voice is harsh. 

Laryngeal Examination. One cord remains in the middle line. 
(See Fig. 31.) 

When both sides are affected there is gradually developing inspi- 
ratory dyspnoea with stridor. The voice is nearly normal. 



Fig. 31. 




Paralysis of the left recurrent nerve : inspiration. (Gottstein.) 

Laryngeal Examination. The glottis is a narrow cleft which becomes 
still narrower on inspiration. 

Complete Paralysis of the Recurrent Laryngeal Nerve. 
Symptoms. Unilateral paralysis. A weak toneless voice which goes 
into a falsetto when the patient endeavors to speak loud. 

Laryngeal Examination. The cord and arytenoid body are in the 
cadaveric position, viz., half-way between the phonating and the in- 
spiratory positions. In phonation the other cord passes beyond the 
middle line, and the glottis is slanting. The edge of the paralyzed 
cord is excavated. 

Bilateral paralysis. Aphonia and inability to cough and expectorate. 

Laryngeal Examination. Both cords are in the cadaveric position 
and their edges excavated. 

The adductors are usually paralyzed before the abductors, and one can 
see all the intermediate stages by close watching. 

Causal disease. The conditions which give rise to the paralysis are 
numerous. It may arise from simple catarrh or from hysteria. More 
often it is due to pressure on the vagus or recurrent laryngeal, or some 
disease affecting these nerves or their roots. 

The causes of pressure are : Aneurism of the subclavian or aorta, medi- 
astinal tumor, tubercular bronchial glands, a tubercular apex of a lung, 
cancer of the oesophagus, goitre, or carcinoma of the pleura. 

The diseases are : Diphtheria, tumor, softening or hemorrhage into the 
brain, bulbar paralysis, neuritis, typhus, cholera, variola, articular rheu- 
matism, toxaemia (?), sclerosis of the cord, progressive muscular atrophy, 
and paralytic dementia. 

Tumors of the Larynx. 

Both benign and malignant growths are seen. They give rise to the 
same group of symptoms. At first dysphonia or apJionia takes place. 
The impairment of voice may continue for a long period of time before 



216 



SPECIAL DIAGNOSIS. 



dyspnoea arises. This develops very gradually, and in some few cases 
is attended by an irritative cough. 

The general symptoms are not marked in benign eases. In the malig- 
nant forms they are pronounced, but characterized by the development 
of cachexia later than in carcinoma elsewhere. 

The most common form of the benign growths is papilloma. The 
growth may spring from the true or false cords, the aryteno-epiglottic 
ligaments, rarely the posterior surface of the epiglottis. The tumor has 
a broad base. There may be one only, or they may be multiple, and 
may vary in size from a split pea to a walnut. Three varieties are met 
with : 1. Small warty growths, usually on the cords, dark red in color 
and seldom larger than a bean. 2. Groups of raised white papilla? on a 
broad base, also growing on the cords. 3. Large, red, mulberry or 
cauliflower-shaped growths, partly villous, partly warty, which fill up 
the whole larynx. 

Fibroma. It appears as a hemispherical, pedunculated tumor of 
dirty-white, reddish, or dark-red color, more or less dense in consist- 
ency. It is usually single, and grows most frequently from the cords. 
When seen in its smallest size, it is known as the " singer's node." It 
may be as large as a hazelnut. 

Malignant Tumors. In addition to the symptoms indicated in benign 
tumor, pain and hemorrhage occur. 

Both carcinoma and sarcoma are found ; the latter is very rare. 

Carcinoma. The most common form is the epithelioma, although 
the medullary and scirrhus have been described. The epithelioma is seen 
as a circumscribed, hemispherical, warty or cauliflower-like formation, 
varying in size, or as a knotty infiltration projecting into the larynx. 
The medullary form is larger, soft and bloody, and rapidly ulcerates. 
Scirrhus is firm and hard. The structure of the larynx is gradually 
invaded, with necrosis of the tissues. Perichondritis and abscess fre- 
quently ensue. 

In carcinoma of the cords two modes of growth are seen. 

In the polypoid form the tumor develops on the cord like a warty 
growth, sometimes papillary and of a reddish gray color. In diffused 
cancer of the cord the structures are red and knotty and the tissues 
invade the surrounding tissue without distinct demarcation. 

Sarcoma. The tumor has a broad base, is shining in appearance, and 
sometimes lobulated. Sometimes the structure is dark red or yellow. 

The diagnosis of malignant disease of the larynx is based upon 
the association of symptoms of laryngeal disease with pain, and with 
the characteristic appearances found on inspection, occurring after the 
middle period of life, lasting from six to nine months only, with the 
development of cachexia aud emaciation without fever. Enlargement 
of the cervical glands points to cancer. Simple and syphilitic peri- 
chondritis must be excluded. 

Tuberculosis of the Larynx. 

The existence of primary laryngeal tuberculosis is doubtful. It 
cannot be proven clinically, and the majority of cases, at least, are sec- 



DISEASES OF THE NOSE AND LARYNX. 217 



ondary to tuberculosis of the lungs. The manifestations of tuberculosis 
of the larynx may be either a simple persistent catarrh, an infiltration 
or ulceration. The symptoms vary according to the lesion. 

a. Catarrh. There is a slight hoarseuess and the voice tires easily. 
Often paresthesia or peculiar sensations in the larynx are present. 
Cough, when due to this alone and not to the process in the lungs, is 
short and dry. 

Laryngoscopic examination is either negative or shows a peculiar 
ansemia of the mucous membrane. 

b. Infiltration. At first the symptoms are those of simple catarrh, 
then the alteration of the voice increases even to aphonia ; there is a 
feeling of dryness or soreness in the larynx, and dysphagia. The cough 
is very slight and is usually wholly disguised by the cough due to the 
disease in the lungs. There is some difficulty in expectoration. 

Laryngoscopic Examination. Attention is first attracted by the 
marked anemia of the mucous membrane. At first there are slight 
intumescences of tubercular infiltration, not well outlined, and gray in 
color. They are most frequently found in the inter-arytenoid space, less 
often on the false cords and arytenoid cartilages, rarely on the epi- 
glottis. 

1. A hill-like prominence between the arytenoid cartilages either in 
the middle or on one side. In phonation it presses between the cords. 

2. When a false cord is affected the whole of it is usually infiltrated, 
forming a tumor-like swelling which often hides the vocal cords. 

3. Vocal cords. Usually only one cord is at first affected. It is 
thickened and the free border is red. Sometimes the free edge seems 
split. The infiltration may extend to the subcordal region and cause 
a hypoglottic laryngitis. 

4. Epiglottis. Infiltration of the epiglottis is rarer than oedema after 
ulceration, and care must be taken not to confound these conditions. 
The whole epiglottis, or only portions of it, may be affected. It is 
thickened and curled upon itself, and not freely movable. 

5. Arytenoid cartilages. They appear enlarged and puffy, and often 
fixed from perichrondritis. 

c. Ulceration. The symptoms are the same as those of infiltra- 
tion, but the dysphagia and pain are greater. It occurs in the 

1. Inter-arytenoid space. The mucous membranes are notched with 
irregular projections. When the ulcer is visible it is irregular and of a 
dirty-gray color. 

2. False cords. The ulcers are flat and aphthous with a pale-white 
base and a membranous deposit. The mucous membrane sometimes 
appears sieve-like. 

3. Aryteno-epiglottic ligaments. The ulcers are superficial and run 
lengthwise of the ligament. 

4. Vocal cords. The ulcers are either on the upper surface or on the 
edge of the cords. The former are superficial and seldom destructive. 
Those on the edge are either small separate ulcers or long ones, affecting 
the whole border. The circumscribed ulcers occur usually at the 
posterior portion of the cord and on the processus vocalis. The ulcers 
of the whole border are often very destructive. 



218 SPECIAL DIAGNOSIS. 

5. Epiglottis. Tubercular ulcers of the epiglottis occur only on its 
laryngeal side. They are either aphthous and superficial, or deep, and 
arise from the breaking clown of previous infiltration. Sometimes tuber- 
cles can be seen at the edge of the ulcers, but they are of no diagnostic 
value, as similar nodes are seen with non-tubercular ulcers. The 
epiglottis is usually thickened and cedematous. 

Diagnosis. Tuberculous ulcer occurs most frequently in the male 
sex, and during the period ranging from eighteen to thirty years of 
age. If the symptoms develop in the course of phthisis, or in case 
that affection cannot be recognized, if there is a history of infection, or 
exposure, and if bacilli are found in the sputum, the diagnosis is not 
difficult. A portion of the diseased mass may be removed for micro- 
scopic examination or inoculation. In examining the secretion for 
tubercle bacilli, it is to be remembered that the exudation may have 
been brought up from the lungs. The examination in cases of phthisis 
is of little practical value, except to determine whether the ulceration 
present may be syphilitic and grafted upon a tuberculous disease of the 
lungs. Enlargement of the glands of the neck is often present, but not 
diagnostic. 

Fever is present, and, indeed, may be an important diagnostic feature 
in cases of doubt. The temperature should be taken every two hours, 
for the morning or evening exacerbations may not be present. Emacia- 
tion ensues, and sooner or later the hectic phenomena and signs of 
tubercle in other structures arise. When tuberculous ulceration of the 
larynx occurs in the course of local pulmonary tuberculosis the disease 
runs a much more rapid course. 

The laryngeal symptoms are not diagnostic. Pain may be the most 
distinct. The appearances observed by the laryngoscope are more char- 
acteristic. Local anasmia with paresthesia, paresis of the cords, and 
short cough, or an obstinate diffuse catarrh, are suspicious symptoms. 
The peculiar ridged infiltration between the arytenoids is almost invari- 
ably tubercular. 

Isolated thickenings anywhere in the larynx which shade gradually 
off into the normal tissue can be only tuberculous or syphilitic. The 
regularity and number, with anemia and lack of inflammatory signs, 
w 7 ill usually distinguish the tuberculous from the syphilitic. The ulcers 
are non-erosive. Syphilitic ulcers do not often occur, except on the edge 
and lingual side of the epiglottis and on the cords. They extend more 
rapidly than the tuberculous, and may be continuous with ulceration in 
the pharynx. The area of ulceration may extend to the base of the 
tongue, which is very infrequent in tuberculous disease. In syphilitic 
ulceration scars or cicatrices are seen ; they are absent in the tuberculous 
form. Laryngoscopic examination in tuberculous ulceration is difficult, 
causing great pain ; in syphilis comparatively little pain attends exami- 
nation. 

Syphilitic Affections of the Larynx. 

Mucous patches, papules, infiltrations, or gummata may be present in 
the larynx for some time with no symptoms whatever. Usually a change 
in the voice is the first symptom noticed, due either to the catarrh or to 



DISEASES OF THE NOSE AND LAKYNX. 219 



ulcers, scars, infiltrations, or gnmmata affecting the cords. There is 
often a feeling of pressure or a tickling sensation. Pain is not usual, 
and when present is very slight. Dysphagia occurs only when the 
epiglottis is extensively ulcerated. There is little or no cough. 

Laryngoscopy Examination. The appearances vary with the 
condition. 

1. Catarrh. Nothing characteristic to be seen. 

2. Mucous patches. These are flat elevations of 3 to 7 mm. diameter, 
oval or circular, and of a whitish-gray color. When the epithelium is 
lost they appear yellow and purulent. There is no tendency to ulcera- 
tion, and the patches soon disappear, even without treatment. They 
occur usually from three to nine months after the infection. 

3. Infiltrations. Usually these are overlooked, as they produce no 
symptoms. They are diffuse thickenings in various parts of the larynx, 
most often on the epiglottis. This may be uniformly thickened or only 
a part of the edge. The cords may be so swollen as to cause dyspnoea. 
Usually an ulcerated spot is seen in the centre of the infiltration. The 
mucous membrane is either normal or reddened. Infiltrations appear 
three to four or more years after infection. 

4. Gummata. They appear as round prominences of the same color 
as the surrounding tissue. They occur on either side of the epiglottis, 
on the ary-epiglottic folds, often in the inter-arytenoid space, on the false 
cords, and on the under surface of the vocal cords. If they break 
down deep ulcers form, leading to extensive destruction of the parts. 

5. Ulceration. Syphilitic ulcers are circular, deep, with a sharp 
border and inflammatory areola, and overlaid with a whitish-yellow 
deposit. They develop from an infiltration or a gumma, and not on 
an unchanged surface. Ulcers on the upper surface of the epiglottis 
are always syphilitic. 

The diagnosis rests upon the history of infection, the objective signs 
of syphilis indicated by pigmentation or recent eruption, scars, peri- 
ostitis or nodes on the bone, and enlarged glands. The laryngeal 
symptoms are not diagnostic, save that pain is absent in spite of exten- 
sive ulceration, while difficulty of deglutition on account of food 
entering the larynx is of frequent occurrence. The larnygoscopic 
appearances, as indicated above, are characteristic of this affection. In 
obscure cases the distinctions spoken of in tuberculosis are of diagnostic 
value. 

Although the patient may be broken down and cachectic the febrile 
range is not high, unless perichondritis occurs, or the onset of pneu- 
monia arises on account of food in the air-passages. 

Lupus. 

In this affection, probably tuberculous, there is soreness and slight 
dysphagia with slight hoarseness, deepening to dysphonia or even 
aphonia. In the later stages dyspnoea can arise from infiltration or 
scar contractions. Lupus is usually present also in the shin of the 
face and in the mouth and pharynx. 

Laryngoscopic Examination. Isolated or grouped nodes flowing 



220 



SPECIAL DIAGNOSIS. 



together into patches are seen most frequently on the epiglottis. Later 
ulceration occurs with loss of substance and scar formation. 

Lepra. 

The symptoms are dysphonia and dyspnoea. Usually lepra is present 
elsewhere. 

Laryngoscopic Examination. The epiglottis is swollen, red, and 
vascular, the arytenoid bodies and false cords dark red to bluish, the 
cords injected and thickened. Nodes from the size of a pin-head to 
that of a pea are seen on epiglottis, arytenoid bodies, and false cords. 
Then follow ulceration and loss of substance. 

Foreign Bodies. 

These may be particles of food, false teeth, pins, or almost anything 
small enough to enter the larynx, which could by any possibility be 
placed in the mouth. The symptoms are cough, often with spasm of 
the larynx and dyspnoea. There is pain only when the foreign body 
is sharp and capable of injuring the mucous membrane. Hoarseness 
is observed when the cords are interfered with. 

Laryngoscopic examination is not always possible on account of the 
reflex spasm. When examination is possible the body can usually be 
seen. 

The Larynx in Other Diseases. 

In Nervous Diseases. Laryngeal symptoms due to lesions of the 
nervous system. (See Cerebral Localization.) 

Cerebral hemorrhage. 1. Aphasia. The movement of the muscles is 
normal, but they cannot be controlled by the will. Caused by hemor- 
rhage in the cortex or along the course of connective fibres. 

2. Recurrent paralysis. Due to hemorrhage in the medulla. 

3. Symptoms of bulbar paralysis. Same cause. 
Encephalomalacia. (Softening.) When in the brain, aphasias re- 
sult ; when in the medulla, bulbar symptoms. 

Tumors of Cerebrum. The symptoms are, according to location, 
aphonia, aphasia, or paralysis of the cords. 

Bulbar Paralysis. We have, of course, the other symptoms of the 
disease. The voice becomes weak and monotonous without modulation. 
High tones cannot be made. It progresses to hoarseness and finally 
aphonia. Particles of food and drink enter the larynx. Paresis or 
paralysis of the cords. 

Multiple Sclerosis. The speech is slow, uncertain and scanning, later 
hoarse. Laughing and crying are accompanied by peculiar yawning 
inspirations. 

Laryngoscopic Examination. Slight paresis of the cords is seen. 

Posterior Sclerosis (Tabes). The muscles act very slowly. Some- 
times symptoms of irritation, as tickling or burning in the larynx, with a 
dry cough, occasionally severe paroxysms of coughing even to spasm 
of the larynx, occur. In rare cases a phonetic spasm has been observed. 
Less often pareses or paralyses of the various muscles occur, most fre- 



DISEASES OF THE NOSE AND LARYNX. 221 

quently the posticus, next the recurrent. Sensibility may or may not 
be disturbed. 

Amyotrophic Lateral Sclerosis. There is a mixture of bulbar with 
spinal symptoms. (See Sclerosis.) 

Progressive Muscular Atrophy. Very late occurs this same mixture 
of symptoms. 

Paralytic Dementia. There may be disturbances in articulation with 
paresis and paralysis of the cords. 

Chorea. There may be a tremor of the cords from under-tension, 
but probably no true choreic movements. 



CHAPTER II. 



DISEASES OF THE LUNGS AND PLEURiE. 

The various affections of the lungs occur without any change in the 
volume of air in the lungs, or are attended by an increase or diminution 
in the amount of air. 

I. Diseases with Normal Amount of Air. 

Affections of the Bronchial Tubes, except Asthma. 

II. Diseases with Increased Amount of Air. 
Enlargement of the Chest. The enlargement with in- 
creased amount of air may be unilateral or bilateral. It 
seems anomalous that the more air in the thorax, the greater 
need for air and hence the occurrence of dyspnoea. 

1. Asthma. 

2. Emphysema. 

III. Diseases with Diminished Amount of Air. 

A. The Consolidations. The consolidations may be local, 

unilateral, or bilateral. 

1. The congestions. 

2. Pulmonary embolism and thrombosis. 

3. Pneumonia. 

4. Broncho-pneumonia. 

5. Chronic interstitial pneumonia. 

6. Pulmonary tuberculosis. 

7. Abscess of the lung. 

8. Gangrene of the lung. 

9. Collapse of the lung. 

10. Cancer and other new growths of the lung. 

11. Hydatid disease of the lung. 

B. Diseases of the Pleura. 

1. Diminished amount of air from inhibition of move- 

ment on account of pain. 

2. Diminished amount of air from the physical condition 

within the thorax. 

The lungs are composed of a relatively small amount of tissue. They 
are made up of tubes and canals. The tissue which composes the struc- 
ture of the lungs independent of the canals, the connective tissue, is 
liable to the same morbid processes that affect it in other situations. 
But, curiously, it is not often subjected to irritants on account of which 
acute inflammation takes place, while chronic inflammations occur sec- 
ondarily, in the large majority of cases, to processes in the channels. 



DISEASES OF THE LUNGS AND PLEURA. 



223 



Diseases of the lungs therefore are the diseases of its channels, and the 
symptoms that arise are due to morbid alterations of them (1) by pro- 
cesses common to the structure of such channels, and (2) by obstruction 
of them. The channels are three : first, for the passage of air; second, 
for the flow of blood ; and third, for the flow of lymph. 

Symptoms due to the Morbid Process. The air-tubes are lined 
with mucous membrane which is subject to morbid processes that attend 
any such lining — congestion, or acute and chronic inflammation — with 
a flux as the characteristic symptom. The muscle and elastic tissue of 
the canal become involved iu the process. The former undergoes 
spasm with or without mucous membraue inflammation (asthma). 
Grave disaster does not arise until degeneration takes place — then the 
power of confining the air or driving it out is lost, and emphysema 
results. 

In the blood canals, hyperemia (congestion), embolism and throm- 
bosis, and secondary oedema take place; while in the lymph canals, 
inflammation (acute and chronic pleurisy), and transudation (hydro- or 
hemothorax) take place. Now, the symptoms that arise in each or all 
of the above processes — pain, local discomfort, mucous or purulent 
discharge, serous or purulent exudation, and fever — are not different 
from those which are found in similar tissues in other localities. 

Symptoms due to Obstruction. But in addition to the group of 
symptoms thus indicated there is a group due to obstruction of the 
various channels, and hence, interference with the function of the lungs. 
The symptoms are purely mechanical. 

1. Dyspnoea occurs from obstruction of either caual. It is as pro- 
nounced in asthma or capillary bronchitis as in embolic obstruction (fat 
embolism), or congestion and stasis in the bloodvessels. It occurs when 
the canals are occluded by extrinsic causes — foreign bodies in the 
bronchi, or pleural effusions. 

2. Cyanosis. As a sequence of the above symptom we have another 
vivid picture — the development of cyanosis from interference with 
aeration. 

Symptoms from Other Causes. Other structures (the bony 
thorax and its muscles) are required for the performance of the func- 
tion of the lung, the aeration of the blood. 

Of these more particularly we have : first, muscles, to hasten the 
movement of the air ; and second, a nervous mechanism to control the 
muscles. Inactivity of the former, from pain, from debility, or from 
paralysis through disease of the nerves, practically occludes the canals, for 
the normal contents cease their movement or lessen its speed, and there- 
fore the amount of air is lessened — hence, again, dyspnoea. The nervous 
mechanism not only controls the large muscles of the exterior through 
a centre stimulated or depressed by various influences, chiefly the 
blood, but also receives and sends impressions to the muscles of the 
canal, on account of which we have (a) cough or (6) bronchial spasm 
with dyspnoea. This nervous mechanism, with its centre of control, 
is in relationship with higher and lower centres, and the nerve that 
connects it with its organ supplies other organs or anastomoses with 
other nerves. Hence, we may have: A. A central a fiction, causing 



224 



SPECIAL DIAGNOSIS. 



pulmonic symptoms from these causes — 1. Because higher centres in- 
fluence the lower pulmonary centre, as we see in hysterical cough, or 
emotional cough, and in asthma. 2. Disease affects the region of the 
centre, as in tumor or in bulbar or glosso-labio-laryngeal paralysis. 
3. Irritants act upon the centre, as urea, exciting ursemic asthma. 
B. An affection of the nerve trunk, as from the pressure of an aneurism 
or morbid growth. C. Reflex influences through the pneumogastric 
and correlated nerves. The asthma of nasal disease or of peripheral 
irritation elsewhere, and reflex cough, is of this nature. Corollary; 
Lung symptoms, chiefly dyspnoea and cough, may be due to local causes 
(affections of the muscles), or to causes at a distance, operating directly 
through the pneumogastric centre, or the nerve trunk, or by anasto- 
moses in a reflex manner. The practical deduction is, to look further 
than the lungs in the investigation of pulmonic symptoms. Lung 
symptoms are not so often expressions of disease in other parts, nor do 
diseases of that organ so often have their expression in other organs, as 
is true in gastric diseases. 

Affections of the Pleura. In diseases of the pleura, one 
side is usually affected, but whether the disease is unilateral or bilateral 
we have simple inflammation, and inflammation with exudation into 
the pleural cavity. In both forms there is diminution of movement, and 
hence less air entering the affected lung, although the cause for the 
diminution in the amount of air is different in each case. In acute 
inflammation, the lessened amount of air is present because of physio- 
logical reasons. The movement of the affected side is inhibited by 
pain, hence diminution of expansion and lessened ingress and egress 
of air follow. It is true, enfeeblement of breath-sounds and fremitus, 
with diminished expansion, alone indicate the diminution. On the 
other hand, in acute inflammation with exudation, the diminution in 
the amount of air occurs on account of physical reasons. The effusion 
encroaches upon and causes diminution of the air-space, and hence 
lessens the amount of air. It will be remembered that the physical 
signs of diminution in the amount of air from effusion are quite distinct 
from the physical signs due to consolidation. 

The Lungs and Heart. The relationship of the pulmonary vascular 
channels to the remainder of the circulation is very close. Overfilling 
of the pulmonic bloodvessels, and hence dyspnoea, may be due to 
alterations or changes in the central pump, the heart ; or in the vessels 
between — as from the pressure of au aneurism. The nature and im- 
portance of any lung symptoms cannot be appreciated without an 
investigation of the heart and the blood-ways. Many pulmonic con- 
gestions are due to dilatation of the heart, and are relieved by digitalis. 
At the other end of the beam, it may be noted that lung diseases cause 
heart disease; from backward pressure of blood columns in overdis- 
tended vessels, a dilated right heart follows. 

Space forbids tracing out the effects of the blocking of channels, but 
it is suggestive that all the aeration of the body takes place through the 
first set of tubes, that all the blood of the body passes through the 
second, and that the third is an enormous drainage area of lymph. The 
student can readily appreciate how profoundly diseases of the lungs 



DISEASES OF THE LUNGS AND PLEURil. 



225 



must affect the general system. Apart from the nerves, the tie that 
binds the other organs to them is the blood. As the lungs enrich it 
with oxygen, so the organs act with vigor. Imperfect oxygenation 
soon causes diminution of all function, with the secondary effect on the 
blood of the production of anaemia. 

Infectious Diseases. The lungs are subjected, in a high degree, 
to one group of processes — those of infection. Pronounced symptoms 
due to the process and to the blocking of channels are produced. They 
are seen in tuberculosis, pneumonia, the bronchitis of infectious diseases, 
the pleurisy of septic processes. The general symptoms belonging to 
such processes are detailed elsewhere. 

Relative Value of Subjective and Objective Symptoms. 
The subjective symptoms are few, and, as will be seen later, are com- 
mon to so many diseases that they are of little diagnostic value. For- 
tunately the physics of the lungs come to our relief. Disturbance of 
this respiratory function causes a physical change. The effect of the 
occlusion of channels is mechanical or physical, and also causes a 
physical change in the lung. 1. The objective symptoms are possible 
because of the physiological movement of air. Sounds attend the 
movement of air in health ; no sounds occur if the air movement is 
checked, or abnormal breathing and new sounds (rales) are created. 
2. They are possible because of physical changes in the structure. Air 
is replaced by solid structure ; the physical condition of the lung 
changes. The objective signs of these conditions are determined by 
means required to secure physical data : inspection, palpation, percus- 
sion and auscultation. 

Diagnosis. The diagnosis of disease of the lungs is attained by the 
collection and consideration of data obtained by inquiry and data 
obtained by observation. By inquiring we learn, first, the history of 
the case; second, the subjective phenomena. By observation the 
objective phenomena of the disease are determined. The objective 
phenomena are secured, first, by physical examination; second, by an 
examination of the sputum, and third, by an examination of the 
fluids secured by puncture. The examination of the sputum and of 
aspirated fluids is made with the microscope and by bacteriological 
methods. For convenience the objective phenomena will be considered 
first. 

It is not generally difficult to distinguish diseases of the lung from 
affections of other structures. It is true pleurisy and pleurodynia are 
often distinguished with difficulty. We are called upon, also, to decide 
between pleurisy and sub-diaphragmatic inflammation, a pleural and 
hepatic inflammation, a pleuritis and pericardial inflammation, and 
between cardiac and pulmonary disease, especially when both are 
present and it is desirable to determine the primary affection. The con- 
tiguous relations of the organs make this necessary, but with care in 
ascertaining the history and the subjective and objective symptoms the 
distinction may not be difficult. 

In chronic disease, affections of the lungs, of the mediastinum, and of 
the great vessels must be distinguished from one another. An aneurism 
may simulate chronic phthisis or mediastinal disease^ 

15 



226 



SPECIAL DIAGNOSIS. 



The Data Obtained by Observation. 

The Objective Symptoms. By physical examination of the lungs 
we ascertain — 1, their degree of activity (movement); 2, the physi- 
sical condition of the parts subjected to examination : the disease is not 
diagnosticated. If abnormal signs are detected they simply indicate 
an abnormal physical condition of the part. As the lungs in health 
contain air, any physical change that takes place causes either an in- 
crease or diminution in the amount of air. This may be general 
(bilateral), or limited to one side (unilateral), or to a smaller area 
(local). In an examination of the lungs we might be content to 
answer the question, Is there an increased amount of air, or a dimin- 
ished amount in the parts suspected to be the seat of disease? A cor- 
rect answer to this question, and to an inquiry as to the cause of the 
increase or diminution, would explain any abnormal physical condi- 
tion. The answer can be determined by percussion, a method employed 
to detect such physical condition under any circumstance. But fortu- 
nately, as adjuncts we have the phenomena that can be elicited by means 
of inspection, palpation, and auscultation. The latter methods elicit 
control data on account of the movement of the lung, and because 
sound is created by the movement. 

Value of Inspection and Palpation. Too much emphasis has been 
placed in the past on auscultation and percussion in the study of the 
diseases of the lung. It has grown to be too much the habit to rely on 
these methods to the exclusion of the simpler and yet at the same time 
fully as valuable methods — inspection and palpation. The latter have 
been employed for a long time in the study of the objective phenomena 
of disease. The former are comparatively modern methods. They 
required special cultivation of the senses not usually employed in 
observation, and exhaustive comparative research, to put the findings 
on an accurate basis. The impetus derived from this study has caused 
undue stress to be placed upon them as methods of diagnosis. The 
pernicious habit of examining the patient without removal of clothing, 
on account of haste upon the part of the physician, or improperly applied 
modesty upon the part of the patient, has also led unfortunately to the 
neglect of inspection and palpation. It is proper to insist that the 
data derived by inspection and palpation are as important and valuable 
as those derived by other means. The facts derived through them 
are even more suggestive or diagnostic of physical conditions. The 
phenomena observed are more positive and surrounded by fewer quali- 
fications. 

The Regions of the Chest. For the purpose of bearing in mind the 
relations of the organs to the surface of the chest, and the localization 
and proper recording of the seat of the disease, the chest is divided 
into regions. The regions correspond to anatomical points on the 
surface of the chest, and are subdivided by transverse and vertical 
lines. Knowledge of the landmarks which on the surface indicate 
the position of the parts underneath is of great importance in diagnosis. 
The regions in the anterior portions of the chest are : The supra- 



DISEASES OF THE LUNGS AND PLEURiE. 227 



clavicular region, above the clavicle ; the infra-clavicular region, below 
the clavicle, extending to the third rib ; the mammary region, from 
the third to the sixth rib,. In the axilla two regions suffice — the 
upper and lower — the position of the disease being more definitely 
determined by association with ribs and interspaces. Posteriorly the 
regions are : the supra-scapular, above the scapula ; the scapular region, 
and the infra-scapular region; the region between the scapula and the 
spine is known as the interscapular region. The vertical lines are 
to the right and left of the median line : (1) the parasternal line, 
which is drawn midway between the edge of the sternum and the sec- 
ond line, which is (2) the mid-clavicular line, drawn from the middle 
of the clavicle, generally passing through the nipple in males; (3) the 
anterior axillary line, drawn from the anterior fold of the axilla ; (4) the 
mid-axillary line, from the centre of the axilla ; (5) the posterior 
axillary line, from the posterior fold of the axilla. In the back one 
line is sufficient — the scapular line, drawn through the angle of the 
scapula when the arm is at rest at the side of the patient. For trans- 
verse lines the ribs and interspaces are used. In this way the exact 
location of a diseased area can be indicated. In order that accuracy 
may attend its localization, knowledge of the methods of determining 
the landmarks, and especially counting the ribs, is essential. 

The Angles of the Thorax. The costal angle is the angle of the rib. 
It varies during the act of respiration. In inspiration the rib rises 
as the sternum projects, and apparently elongates ; the angle becomes 
more obtuse ; in expiration the sternum falls, the ribs become more 
slanting, and the angle is more acute. 

The epigastric angle. This angle is formed by the convergence of 
the ribs of both sides to the xiphoid cartilage of the sternum. On 
inspiration, it is obtuse, increasing as the ribs rise ; in expiration it is 
more acute. 

Method of Counting Ribs and Interspaces. The first rib corresponds 
to the clavicle ; the first interspace is the region between the clavicle, or 
first rib, and the second rib ; the subsequent number of an interspace cor- 
responds to the number of the rib above it. The following from Holden 
is of great importance to remember, particularly when the ribs of fat 
persons are counted : 

a. The finger passed down from the top of the sternum soon comes 
to a transverse projection, slight, but always to be felt, at the junction 
of the first with the second bone of the sternum. This corresponds with 
the middle of the cartilage of the second rib. 

b. The nipple of the male is placed in the great majority of cases 
between the fourth and fifth ribs, about three-quarters of an inch 
external to their cartilages. 

c. The lower external border of the pectoralis major corresponds with 
the direction of the fifth rib. 

d. A line drawn horizontally from the nipple round the chest cuts the 
sixth intercostal space midway between the sternum and the spine. This 
is a useful rule in tapping the chest. 

e. When the arm is raised, the highest visible digitation of the ser- 
ratus magnus corresponds respectively with the seventh and eighth ribs. 



228 



SPECIAL DIAGNOSIS. 



/. The scapula lies on the ribs from the second to the seventh, 
inclusive. 

g. The eleventh and twelfth ribs can be felt, even in corpulent persons, 
outside the erector spinas, sloping downward. 

h. One should remember the fact that the sternal end of each rib is 
on a lower level than its corresponding vertebra. For instance, a line 
drawn horizontally backward from the middle of the third costal carti- 
lage, at its junction with the sternum, to the spine, would touch the body, 
not of the third dorsal vertebra, but of the sixth. Again, the end of the 
sternum would be at about the level of the tenth dorsal vertebra. Much 
latitude must be allowed here for variations in the length of the sternum, 
especially in women. 

It is important to recognize the relation of the ribs to the vertebrae. 
The first rib articulates with the first dorsal vertebra, which can be 
located by the position of the prominent spine of the seventh cervical 
vertebra; even in very fat people this prominence can be recognized. 
The remaining ribs, except the eleventh and twelfth, have facets of 
articulation on two vertebras : as the second rib, with the second and third 
vertebras. The eleventh and twelfth articulate with the last dorsal. 

Topographical Anatomy. The following anatomical points are worthy 
of remembrance : 

The top of the sternum is on a plane with the lower border of the 
second dorsal vertebra behind. The junction of the first and second 
portions of the sternum is known as the angle of Ludwig. It is oppo- 
site the middle of the second rib, and is on a plane with the lower border 
of the fourth dorsal vertebra. The junction of the body of the sternum 
to the xiphoid cartilage is on a plane with the lower border of the eighth 
dorsal vertebra. 

The apex of the diaphragm is on a level with the eighth dorsal 
vertebra. 

The trachea bifurcates at the plane which includes the angle of 
Ludwig and the fourth dorsal vertebra. 

Purulent effusions in the left pleural sac frequently point at the fifth 
interspace beneath the nipple, because this is the weakest point of the 
chest covering. A little external to the inferior angle of the scapula 
and the eighth and ninth interspaces a similar weak point is found. 

Limits of the Lungs. The apices of the lungs reach three to seven 
centimetres (one and one-fifth to two and three-quarters inches) above 
the clavicles in front ; behind they rise as high as a line drawn trans- 
versely through the spinous process of the seventh cervical vertebra. 
The lower margin of the right lung, when the chest is passive, commences 
at the insertion of the sixth rib with the sternum, and runs parallel with 
the upper border of the sixth rib to the axillary line. At this point it 
descends to the upper margin of the seventh rib. On the left side the 
lower limit extends as far downward as the right. Posteriority, both 
lungs reach to the tenth rib. With full inspiration the lungs descend 
both in front and behind almost the extent of one interspace, while in 
deepest expiration they are elevated almost to the original position. The 
"complemental space" of Gerhard t is the space at the lower margin of the 
lung and at the point at which the left lung overlaps the heart, in which, 



DISEASES OF THE LUNGS AND PLEURJ . 



229 



during expiration, the surfaces of the visceral and parietal pleura come 
together. In inspiration the thin layer of lung in both situations is 
insinuated into this space. The heart interferes with the extension of 
the left lung. The figure shows the relationship to the chest wall. The 
space is triangular in shape, extending in the median line from the fourth 
to the sixth rib. The left edge of the triangular area corresponds to 
the edge of the left lung, which, notched for the heart, diverges from 
the median line and runs along the cartilage of the fourth rib. 

Position of the Lobes. The accompanying diagram illustrates the 
position of the lobes of the lungs anteriorly. In the right lung the 
upper lobe in front extends to the fourth rib, in inspiration laterally to 



Fig. 32. 




Outline of the heart, its valves, and the lungs. (Holden.) 

the third, and behind to the spine of the scapula. The lower lobe 
begins with the spine of the scapula and extends to the tenth rib behind, 
and from the fourth to the tenth ribs when fully expanded in the 
axillary region. The middle lobe is not seen behind ; it extends 
between the third and fourth ribs in the axillary region in inspiration. 
In front it extends from the lower margin of the upper lobe to the 
sixth rib. 

The upper lobe of the left lung extends to the sixth rib in front and 
to the fourth interspace at the side. Behind, a small portion extends 
above the spine of the scapula, while the lower lobe extends from the 
spine of the scapula to the base of the lung behind. At the sides it 



230 



SPECIAL DIAGNOSIS. 



extends from the lowest limit of the upper lobe to the level of the 
eighth rib. 

Inspection. By inspection we learn (1) the appearance of the exter- 
nal surface, (2) the shape and size, and (3) the movements of the chest. 
The second indicates the capacity of the lungs ; the last, the degree of 
functional activity. 

Methods. The patient must be seated, if possible, in an easy position, 
with the light falling directly on the part or from the side. He should 
be viewed by the observer standing first in front, then behind, and also 
laterally. The arms should fall by the side ; the breathing should be 
quiet and undisturbed by talking or unusual movements. 

The Skin and Subcutaneous Tissue. In health the normal covering 
should be supple, elastic, or of the color previously described of an 
individual in health. It is pale in anseruia and wasting diseases ; yel- 
low in jaundice; pigmented generally or locally from causes previously 
mentioned. It is the particular seat for the parasitic disease, tinea versi- 
color, and, along with other non-specific eruptions, is the seat of suda- 
mina. The veiDS over the surface of the chest should not be very 
distinct. They are distinct when there is interference with the circula- 
tion in the mediastinum by aneurism or morbid growths obstructing the 
veins. The capillaries along the base of the chest are often enlarged or 
more distinct than usual and arranged in a bow corresponding to the 
attachment of the diaphragm. This bow is frequently seen in intra- 
thoracic obstruction. CEderna or subcutaneous emphysema occurs as 
indicated under general inspection. If there is too much fat over the sur- 
face of the chest, the muscles may want tone, and an estimation, therefore, 
of respiratory capacity can be made. Wasting of the fat and muscles 
is seen in phthisis, carcinoma, diabetes, muscular atrophy and paralysis. 

The Shape and Size of the Chest. We appreciate the shape of 
the chest in health by an estimation of the relations of the antero-posterior 



Fig. 33. 



C i 


1 >\ 







Transverse section of healthy adult chest upon level of sterno-xiphoid articulation. 
Circumference = 89 centimetres. (Dr. Gee.) 

and the transverse diameters and by the shape of the transverse section 
of the chest. The latter is an ellipse, and has been described as reniform 



DISEASES OF THE LUNGS AND PLEUKJ3. 



231 



(see Fig. 33). The antero-posterior diameter is about one-third less 
than the transverse. Measurement with the cyrtometer (see Mensura- 
tion) verifies the result of inspection with mathematical precision. In 
children a transverse section is different. It is more circular, and the 
antero-posterior and transverse diameters are almost equal. (See Fig. 
34.) Marked deviations from such section, or in the relations of the 
diameters, are seen in abnormal types of chest. 



Fig. 34. 



Transverse section of an infant's chest, aged nine months. A circle within shows the similarity. 

It is difficult to describe the shape of the chest in health. By 
repeated practice we readily form a judgment of the true shape. No 
rule has been applied to the relationship of the length of the chest to 
the length of the body, but it would seem that the circumference of the 
chest bears such relationship (see Mensuration). In health the chest 
should be symmetrical, the right side probably a little larger than the 
left. In the ideal chest the muscles of respiration should be well de- 
veloped and a moderate amount of subcutaneous fat found. The ster- 
num should project forward from above downward, and the portion 
joining the manubrium and the xiphoid cartilage should be a little 
more prominent than the other part. It is not unusual to see a clearly 
marked distinction between the upper and middle portions of the 
sternum, or an undue projection of one or more of the upper ribs, 
and some striking changes about the xiphoid cartilage, none of which 
are indications of disease. The xiphoid may be depressed, on account 
of which a crater form or funnel-shaped depression is seen (occupation). 
The tip of the cartilage is sometimes drawn inward, but more frequently 
the reverse is noted. 

The Movements of the Chest. The frequency, the rhythm, and the 
degree of expansion, are studied. A complete respiratory act consists 
of two events, inspiration and expiration. Inspiration is active; expira- 
tion, passive. The latter is a trifle longer than the former, as may be 
illustrated by the following proportion — Insp. : Exp. : : 5 : 6. A pause 
follows the act of expiration. The chest increases in circumference 



232 



SPECIAL DIAGNOSIS. 



and in vertical length (descent of diaphragm) in inspiration as the lung 
expands with air. The term expansion is applied to the act of inspira- 
tion ; its degree varies. 

The frequency and character of the movements in health vary in the 
two sexes. The respirations are from 16 to 24 in the minute in a 
healthy adult. In the female they may be 20 to 22. In children the 
frequency of respiration is much greater : under one year 44 per minute, 
and at five years 26. They are increased in frequency in the standing 
position. They are lessened in the horizontal position, increased during 
bodily exertion, with increased temperature of the air, and during diges- 
tion. The hand placed on the epigastrium facilitates counting of the 
respirations. 

The movements of the chest in quiet breathing are more marked in 
the lower half in male adults, and thus the costo-abdominal or dia- 
phragmatic type of breathing is seen. The sternum rises, the ribs are 
elevated and at the same time are drawn forward and outward. 
The antero-posterior and vertical diameters increase. The costal angle 
and epigastric angle become more obtuse. The diaphragm acts con- 
jointly with the external muscles of the thorax, and as it descends the 
epigastric region swells with each inspiratory effort. In expiration the 
sternum falls, the ribs become more slanting instead of horizontal, the 
epigastrium retracts, the angles become acute. The antero-posterior 
diameter and the transverse lessen. The upper half of the chest moves 
more actively in women, and hence the costal or upper thoracic type 
of breathing is seen. The areas below the clavicles and the upper 
portion above the sternum swell more distinctly during inspiration. 
The movements of the lower portion, and especially of the diaphragm, 
are limited. 

The costal type occurs most frequently in children. The type of 
breathing is costal in both sexes during sleep; the same type is ob- 
served during deep respiration. 

The Shape and Size of the Chest in Disease. Enlargement or diminu- 
tion may be seen. Such change may be general or bilateral, unilateral, 
or local. 

1. General or Bilateral Changes in Shape. Enlarge- 
ment. The " barrel -shaped " chest, the type of bilateral enlargement of 
the chest, is seen in health when it is in the state of full inspiration. 
All the diameters are increased, particularly the antero-posterior; the 
length is shortened. A transverse section approaches a circle. (See 
Figs. 35 and 36.) The diameters are almost equal. The ribs are elevated 
and almost horizontal, the epigastric angle is obtuse. The shoulders are 
rounded and elevated, and the scapulae lie flat against the thorax. All 
the muscles of respiration stand out prominently, the neck and upper 
trunk muscles particularly. The individual with bilateral enlargement 
of the chest presents a striking appearance. The neck is short, the arms 
are short; there is undue fulness above the clavicles. As this enlarge- 
ment is attended with dyspnoea, the face is drawn and anxious, and 
the lips usually faintly livid, or purple. 

The movement of the chest in bilateral enlargement. Expansion is 
lessened. The respiratory capacity is diminished. The chest is in a state 



DISEASES OF THE LUNGS AND PLEURA. 



Fig. 35. 




Emphysema with enlargement of the chest. The antero-posterior diameter 
is much increased. (From Page.) 



Fig. 36. 




Bilateral enlargement of emphysema. 
Inner line = emphysematous chest. 

Outer line = a circle drawn to show how nearly the emphysematous 

approaches the circular shape. 
Dotted line = natural adult chest. 

Actual measurement in centimetres. 
Circumference = natural 89. emphysematous 87.75. 
Transverse . . = " 29.6 " 27.25. 

Antero-posterior = " 22.25 " 25.4. 

(De. Gee.) 



234 



SPECIAL DIAGNOSIS. 



of full inspiration and the attendant dyspnoea is known as expiratory 
dyspnoea. The respirations are hurried, the inspirations short, followed 
by prolonged expiration. While the expansion of the chest in health 
extends over an area of three or four inches, when the chest is bilaterally 
enlarged it may be lessened to one and a half inches, or even be as low 
as half an inch. Both the costal and diaphragmatic types of breathing 
are seen in a state of exaggeration. In men the diaphragm acts very 
vigorously at times. Expiration is three or four times as long as in- 
spiration. 

Cause. The increase in size arises because of enlargement of the 
contents of the chest. The increase may be from excess of normal 
contents or from abnormal contents. In nearly all cases it is due to 
an increased amount of air within the thorax (normal contents), as in 
emphysema. In a few instances enlargement of both sides is seen in 
cases of bilateral pleural effusion, but as considerable effusion would be 
incompatible with life, the enlargement from this cause is never very 
great. It is said that in rapidly growing cancer of the lungs, such 
enlargement may occur. 

It must be remembered that emphysema can exist without bilateral 
enlargement of the chest. 

Bilateral Diminution in Size. The type is seen in so-called phthis- 
ical or tuberculous chest. The chest is long, the antero-posterior 



Fig. 37. 




The flat or phthisical chest, short antero-posterior, long transverse diameter. (Gee.) 

diameter small (see Fig. 37), the transverse very much increased. The 
angles are acute, the ribs are slanting, the epigastric angle is particu- 
larly sharp. The shoulders are not high, the scapula? are prominent 
— so marked in many cases that the term alar, or a winged" chest has 
been applied to it. 

Associated with this type of chest the neck is long, the larynx 
(Adam's apple) very prominent, the arms are long. The patient is 
loosely put together ; the length of the long bones is increased. 

It is known as the phthisical, phthisinoid, or tuberculous chest (see 
Figs. 38 and 39). Although the term tuberculous is applied to the 
chest of this description, it does not necessarily imply that an indi- 
vidual with such a chest has, or will have, tuberculosis. It is true 
that in individuals with such type of chest the vulnerability to the 



DISEASES OF THE LUNGS AND PLEURAE. 



235 



action of the tubercle bacillus is more marked, and they are more liable 
to have the disease. Nevertheless a very large number of individuals 
go through life with such chests and die of other diseases. As long as 



Fig. 38. Fig. 39. 




Phthisical, phthisinoid, or tuberculous chest. (Eichhoest.) 



they are not exposed to the exciting cause of the disease they most 
surely will escape its ravages. 

Cause. Bilateral diminution means diminution of contents. The 
extent of air-surface is lessened. 

Fig. 40. Fig. 41. 



f 




Circumference = 42.75 centimetres. Chest of rhachitis. 

Rickety chest. Dotted line indicates the shape of chest (Eichhorst.) 
in an infant about the same age. (Gee.) 

The Chest of Rhachitis. Another type of diminished chest is con- 
stantly referred to. It is known as the chest of rhachitis (see Fig. 40), 
and arises in infancy on account of this disease of the bones. Many 



236 



SPECIAL DIAGNOSIS. 



other shapes are seen to which various names have been given. Among 
the more common is that which causes the "pigeon-breast." (See 
Khachitis, and The Head.) The chest is usually shortened, the sternum 
is much more prominent than in health, the lower portion projecting 
to an unusual degree. The portion of the chest at the junction of 
the cartilages and the ribs is depressed. This tends further to throw 
the sternum outward. The transverse section of such chest resembles 
a triangle with the portions where the base line joins the ribs rounded. 
(See Fig. 40.) The sternum is depressed and the osteo-cartilaginous 
articulations are more prominent in some forms of rickety chest. In 
others the ribs and sternum from above to the fifth rib are prominent, 
and from thence downward to the base are drawn in. In the chest of 
rhachitis the costal angle is usually very acute. (See Fig. 41.) It often 
looks as if pressure as by the hands had been applied to the sides of the 
chest about the anterior axillary line, causing the antero-lateral portion 
to sink inward, while the antero-median portion is projected forward. 

The chest of rickets is attended by enlargement of the articulations 
of the cartilaginous and bony portions of the rib — the rhachitic rosary — 
and by changes in the other bones. 



Fig. 42. 



K 





10 


"■'••-.nS- 





mm %8''~ ,..-''30 



'is -5 

Unilateral enlargement of chest (right side), artificially produced by injecting air into the right 
pleural cavity. Unbroken line : outline before injection. Broken line : outline after moderate 
distention. Dotted line : outline after extreme distention. Figures at bottom of vertical line indi- 
cate the antero-posterior diameter ; along horizontal line, transverse semi-diameter ; remaining 
figures, right and left semi-circumferences. (Gee.) 

The rhachitic chest must not be confounded with such changes in 
shape due to abnormal conditions of the upper respiratory apparatus in 
early childhood. In cases of adenoid disease of the pharynx (see Dis- 
eases of the Pharynx), the change in shape of the chest has been noted. 
The transverse groove is also seen in addition to the projection of the 
sternum forward and the lateral grooves along its borders. This 
extends from the median line along the base of the thorax, correspond- 
ing with the junction of the diaphragm with it. It may mark the 
upper limit of the liver on the right side as it occurred in infancy. 



DISEASES OF THE LUNGS AND PLEURA. 237 



The shape of the chest just described (rhachitic) does not indicate 
any disease of the lungs ; it does indicate deficient respiratory capacity, 
and of course is the tell-tale by which rhachitis in early life or early 
laryngeal and nasal obstruction are recognized. 

Unilateral Changes in Shape. Unilateral Enlargement. This 
can usually be seen more prominently at the base. The ribs are ele- 
vated, the side more rounded, the costal angle more obtuse. The inter- 
spaces are frequently effaced, or fuller than on the corresponding side. 
The movement may be increased or diminished, depending upon the 
cause. The nipple is displaced outward. The scapula of the affected 
side is also displaced outward, and hence the distance from it to the 
spine is greater than on the opposite side. (See Fig. 42.) 

Cause. Enlargement of one side means enlargement of contents. 
It may be due (1) to increase of the normal contents, as in compensatory 
emphysema, in which there is an increased amount of air in the lung, 
or (2) the addition of abnormal contents, as fluid or air in the pleural 
sac. It is the most characteristic sign of pleural effusion. When the 
normal contents are increased the movement is increased; when the 
pleural cavity is filled it is diminished. 

Unilateral Contraction or Diminution in Size. The costal angles are 
sharper, the plane of the anterior or posterior portion, or of both, is 



Fig. 43. 




Unilateral retraction of chest, consequent upon cirrhosis of left lung in a girl of fourteen 
years. The figures indicate antero-posterior and transverse diameters and semi-circuruferences 
of right and left half of chest. (Gee.) 



depressed, and approaches the transverse median plane of the chest (see 
Fig. 43). The semi-circumference is lessened, and the diameter through 
the nipple or any fixed point is lessened. The interspaces are lessened 
in width and may be drawn in. The ribs are closer together, and may 
almost overlap. The movement of the side is lessened. 

Cause. Any diminution of contents will cause diminution of the 
affected side. This may occur from obstruction or compression of 
the bronchi of that side lessening the amount of air in that portion 
of the thorax. Theoretically it may occur in any case where there is 



238 



SPECIAL DIAGNOSIS. 



complete occlusion of the main bronchus. The condition is rare, and 
is accompanied by marked associate emphysema of the other lung. The 
unilateral change is most frequently seen in cases of chronic pleurisy. 
A large portion or even the whole of the lung may be bound down and 
compressed by thickened adhesion. The pleural cavity of the side 
thus affected, save where encroached upon by the heart or by invasion 
of an emphysematous portion of the lung of the corresponding side, 
is completely obliterated. 

Local Changes in Size and Shape. Enlargement and diminu- 
tion are also seen. 

Local Enlargement is particularly noted in the region of the heart and 
great vessels, and will be considered when this division of the subject 
is discussed. A local enlargement in the lower auterior or lateral region 
of the chest may occur in cases of empyema, in which the pus tends to 
be evacuated, or in pulsating pleurisy. Enlargement in diseases of the 
mediastinum is usually seen in the region of the heart and vessels, to 
which reference must also be made. 

Local Contraction. This may be seen either at the apex or the base. 
At the apex the local contraction or diminution in size is seen above 
and below the clavicle. The term flattening is applied to this condi- 
tion. The interspace is sunken and the ribs depressed. It may be 
more readily seen when looked at from behind. Flattening may be 
either in the lateral or posterior region at the base. The anterior and 
lateral, or the lateral and posterior region, are combined in the local 
contraction. 

Cause. The physical condition of the part is the same as in unilat- 
eral or general contraction — contraction or diminution in size of the 
parts underneath. Anything which lessens the amount of air in the 
area corresponding to the contracted part w T ill cause local diminution in 
size, or flattening. This is notably seen in tuberculosis, in which affec- 
tion three processes, alone or in combination, lessen the amount of air : 
First, the occlusion of the bronchioles by the eruption of tubercles, 
on account of which the alveoli collapse ; second, the overgrowth of 
connective tissue which attends the more chronic forms of tuberculosis ; 
third, a localized pleurisy. Local pleurisy, with organization and con- 
traction of the inflammatory exudate, also causes diminution of the 
amount of air underneath the part, or diminution of the contents from 
compression of the adjacent lung structure. In local contractions there 
is generally diminished movement of the part. 

G-eneral Review. It is not to be forgotten that in all these changes in 
shape and size of the chest, with the exception of unilateral enlargement, 
the element of time is necessary to produce them. In emphysema the 
change in shape develops over a considerable period. The unilateral 
and local contractions just spoken of also make slow progress, and hence 
require a more or less chronic disease for their development. The occur- 
rence of pleural effusion may cause unilateral enlargement very rapidly. 

The Movements of the Chest in Disease. Bilateral Changes. 
Frequency. The movements are increased in nearly all forms of dyspnoea. 
(See Dyspnoea.) The frequency of movement varies in many affections. 
They are more markedly increased in the acute lung affections attended 



DISEASES OF THE LUNGS AND PLEURAE. 



239 



by fever, and are especially more rapid in children. Increased frequency 
of respiration does not necessarily indicate pulmonary disease. It always 
is seen in fever, and is a marked phenomenon of hysteria. Conditions 
outside of the chest increase the frequency, as enlargement of the abdo- 
men from any cause encroaching upon the capacity of the chest. The 
respirations are lessened in frequency in cases of disease of the medulla 
in which there is pressure upon the respiratory centre, and in some forms 
of poisoning, as that due to opium. 

Alterations in the Rhythm of Movement. Alterations in the character 
and rhythm of the movement are observed by inspection. (See Dyspnoea.) 
The movements may be (1) slow, and either shallow or deep; (2) rapid 
and shallow or deep; (3) irregular in rhythm. The relation of inspira- 
tion to expiration in health is as 5 to 6 ; in women, children, and the 
aged, 6 to 8. The expiration is longer. The expiration may be pro- 
longed, so that it is far greater in length than inspiration. Length 
of inspiration increased. The degree of expansion and the duration of 
inspiration are increased when there is obstruction in the trachea or 
larynx. Such increased expansion is usually associated with retraction 
of the soft parts of the thorax, especially at the base. The ribs and the 
tissues along the margins of the thorax are drawn in with each act of 
inspiration. The space occupied by the lung above the clavicle may 
also be retracted. The transverse groove is more pronounced. If the 
difficulty of breathing continues, the indrawing becomes very marked, 
and, if the ribs are soft, permanent. Expiration prolonged. Inspira- 
tion is short and quick in cases of emphysema. The expiration is 
correspondingly prolonged, and the muscles of expiration are seen to be 
brought into full action ; the act extends over a long period of time. 

In the consideration of dyspnoea the appearances will be described, 
the action of the muscles of respiration noted, and the position that the 
patient assumes detailed. (See Subjective Symptoms.) 

Irregular Rhythm. By inspection the Cheyne-Stokes type of breath- 
ing can be noted. " Respiratory pauses " of half to three-quarters of 
a minute alternate with a short period of increased activity, and during 
this time twenty to thirty respirations occur. The respirations consti- 
tuting this series are shallow at first, but gradually they become deeper 
and more dyspnoeic, and finally become shallow or superficial again. 
The acts of respiration are carried on by an alternation of pauses and 
groups of modified breathing. Sometimes consciousness is abolished 
during the pause. Often the pupils are contracted and inactive. When 
the respirations begin they dilate. 

Unilateral Changes in Movement. Increased movement of one side is 
seen when the lung of that side is acting vigorously from compensation, 
the other lung being disabled by disease. The whole side moves more 
rapidly and vigorously. The increased movement is associated with 
enlargement of the affected side and hyper-resonance on percussion. 
Unilateral diminution in movement occurs when there is diminution of 
the respiratory surface or occlusion of the bronchial tubes, or from 
causes outside of the lung. The air-space is lessened in cases of pneu- 
monia, tuberculosis, or any affection which fills bronchioles and alveoli 
with inflammatory exudation or fluid. The air-space is particularly 



240 



SPECIAL DIAGNOSIS. 



lessened by the compression of effusions in the pleura, or of contracted 
and thickened masses. Occlusion of the bronchus with diminution of 
the movement of the corresponding side is seen in rare cases in which a 
foreign body fills the lumen of the tube, or in more common cases of 
pressure externally upon the bronchus by an aneurism or mediastinal 
tumor. Outside of the lung lessened movement is caused by (1) inter- 
ference with the muscular activity of that side from rheumatism of the 
intercostal or respiratory muscles; (2) pain seated either in the ribs or 
in the pleura. 

It may be due to acute pleurisy, the patient checking motion of 
the affected side as much as possible, and breathing with the abdom- 
inal muscles, because chest respiration causes acute pain. Impaired 
motion from this cause or from pleurodynia may be suspected when 
it has come on suddenly, and when respiration causes acute suffer- 
ing, usually depicted in the face. Pleurodynia and pleurisy are to be 
distinguished from each other by the presence in the one case of ten- 
der muscles, a more constant and less stabbing pain, and absence of 
fever, cough, and rales ; and, in the case of pleurisy, by the occurrence 
of stabbing pain in respiration, absence of local tenderness, and presence 
of fine, dry, or coarse rales on inspiration, with cough and fever. 

Impaired motion due to pleural effusion is almost always unilateral, 
develops gradually, following an attack of acute pleurisy, is unattended 
by pain on respiration, but is attended frequently by great embarrass- 
ment of the respiration, and sometimes by orthopncea. Fever is usually 
moderate in uncomplicated cases. It is to be recognized by the clinical 
signs mentioned and by the physical signs of fluid in the pleura. 

Impaired motion from chronic pleurisy is of long standing and gradual 
development. The chest wall upon the affected side is retracted, and 
may be very markedly sunken. In the absence of accompanying lung 
trouble there is no pain and no fever. It is to be distinguished from 
other causes of impaired motion by the sinking in of the affected side, in 
sharp contrast with the hypertrophy of the other side ; by the absence 
of fever and pain ; by its chronicity ; and by the physical signs of 
thickened pleura and compressed lung. Impaired motion from pneumo- 
thorax develops suddenly, generally in a person with tuberculosis of the 
lungs. Its appearance is usually precipitated by coughing, and its 
sudden development is marked by intense pain, distention of the affected 
side, great difficulty in breathing, and a very anxious expression of 
countenance. The escape of air into the pleural cavity is followed by 
the development of pleurisy with effusion, so that the affection presents 
the physical signs of air and fluid in the pleural cavity. 

Impaired motion from pressure on a bronchus by an aneurism or 
enlarged lymph gland produces the physical signs of collapse of the 
lung coupled with those peculiar to the cause of the occlusion of the 
bronchus. It develops gradually, the patient having no pain in the lung. 

The motion of the affected side is sometimes impaired in pneumonia, 
when a large portion or the whole of one lung is involved, and the air- 
vesicles are so occluded that very little air can get in. The physical 
signs in these cases resemble those of pleurisy with effusion very closely ; 
but the diagnosis can be made by noting the acute onset of the disease, 



DISEASES OF THE LUNGS AND PLEURJ. 



241 



with high temperature aud frequent respiration, without antecedent 
pleurisy, and by the presence of cough with expectoration containing 
the pneumococcus. 

Local diminution of the movement or deficient expansion occurs under 
the same circumstances in which we find flattened and local contraction, 
and for the same reason. Hence, in the early stages of phthisis, or in 
local pleurisies, deficient expansion is observed. 

Impaired motion, due to consolidation of the lung in tuberculosis, is 
usually limited to one or other apex, aud is accompanied by flattening 
of the affected apex and emaciation. The condition is of gradual de- 
velopment, and presents the usual sigus of tubercular consolidation of 
the lungs (q. v.) 

Sometimes the impaired motion and flattening are due to a superficial 
cavity from tuberculosis or abscess, and when the walls are very thin 
they may be seen to flap feebly with respiration. 

Rarer causes of impaired motion of the lung are cancer and hydatid 
cyst (q. v.) 

Palpation. By palpation the results of inspection are confirmed, 
the character and consistence of tumors ascertained, and the vocal 
fremitus determined. 

Method. The surface should be bared, although the fremitus can be 
detected through a thin layer of linen or gauze. To detect the fremitus 
in front, it is often well to stand behind the patient, with the palms of 
the hands placed over the surface of the chest in front. The opposite 
position is taken to detect the fremitus behind. The axillary region 
must also be investigated. The hands should be warmed and applied 
evenly to the surface. The two sides must constantly be compared, 
either by simultaneous application of the hands on the two sides, or by 
applying the hand first on one side, then on the other. 

Cause. The columns of air in the bronchial tubes are thrown into 
vibration during the act of speaking. The vibrations are transmitted 
to the hand on the surface of the chest. They are known as the vocal 
fremitus. In infants the cry must be relied upon instead of the spoken 
voice. 

Vocal Fremitus in Health. The fremitus on the right side is stronger 
than on the left, because the right bronchus is larger than the left, and 
its angle with the trachea is more acute. The fremitus is stronger in 
persons with deep voices of low pitch because the vibrations are not so 
rapid. It is more distinct, therefore, in males than in females, aud in 
individuals with bass voice. The vocal fremitus is felt more distinctly 
in persons with thin chest-walls. Thick chest-walls and large mam- 
mary glands interfere with the transmission of fremitus. The fremitus 
is not distinct in children because the vibrations are too rapid. 

It is well to become familiar with the vibrations produced by fixed 
monotones in order to appreciate the fremitus. The patient is asked to 
count one, two, three, or to repeat ninety-nine three or four times. 
It is well to observe a fixed rule as to the words used, in order to have 
definitely fixed in the mind the character of the vibrations in health, 
and the departures from the normal in disease. 

16 



242 



SPECIAL DIAGNOSIS. 



Vocal Fremitus in Disease. The vocal fremitus may be increased, 
may be diminished, or may be absent entirely. 

Vocal Fremitus Increased. When the lung is consolidated, vibrations 
are transmitted with greater force to the hand. Fremitus is increased 
in all consolidations, as in pneumonia, tuberculosis, and hemorrhagic 
infarct. (See Fig. 44.) The fremitus may be absent in rare cases of 



Fig. 44. Fig. 45. 




Consolidation : Pneumonia. Vocal fremitus Pleural effusion. Vocal fremitus absent 

increased. (Gibson and Russell.) at a. (Gibson and Russell.) 

pneumonia, in which the large tubes are occluded by exudate. The 
fremitus is increased in the later stages of tuberculosis, when cavities 
have formed, if the walls are dense. 

Vocal Fremitus Diminished. Anything intervening between the lung 
and the surface of the chest which interferes with the conduction of the 
vibrations diminishes the fremitus. The fremitus is diminished in 
cases of thickened pleura and in thin layers of pleural effusion. The 
fremitus is lessened if the columns of air in the bronchi are smaller 
on account of diminution in the calibre of the latter, as in bronchitis 
or in emphysema and asthma. The fremitus is lessened in cavities filled 
with fluid, or when the bronchus is occluded. 

Vocal Fremitus Absent. 1. The vocal fremitus is absent when the 
columns of air are obstructed entirely by occlusion of the bronchus, as 
by the external pressure of a tumor, aneurism, or enlarged gland. 2. 
The fremitus is absent in large accumulation in the pleura of air or of 
fluid, which is a different conducting medium, causing interference with 
the vibrations. They are cut off completely, and result in absence of 
vocal fremitus. (See Fig. 45.) The well-known illustration of strik- 
ing a stone underneath the surface of the water applies. If the ear of 
the listener is above the water the sound cannot be heard. If the ear is 
underneath the water the sound is heard at a long distance from its origin. 
Vocal fremitus is absent in pneumothorax, in hydrothorax, in pyothorax, 



DISEASES OF THE LUNGS AND PLEURJ1. 



243 



and in hemothorax. The same physical condition is present when the 
pleura is greatly thickened, and hence the fremitus is also absent. 

The sounds produced by the passage of air through mucus or fluid in 
the bronchial tubes are transmitted to the hand when it is laid on the 
surface of the chest. They are known as rhonchi. They are felt dur- 
ing inspiration. They may be felt all over the chest in bronchitis, or 
in asthma, as distinct vibrations, sometimes coarse, or again fine, indi- 
cating rapidity of movement. The vibration may be transmitted over 
a localized area in phthisis, due to air passing through fluid in the 
cavity. They are distinct in children in cases of bronchitis, and often 
are the source of much alarm to the parents. 

Friction Fremitus. An exudation of lymph on the surface of the 
pleura often causes a vibration which may be transmitted to the hand. 
It is known as a friction fremitus, and is felt in inspiration. It is 
usually felt at the base of the chest, in front, laterally, or posteriorly. It 
is not modified by coughing, and is increased by full breathing. The 
rhonchi, on the other hand, are influenced by cough and breathing. 

Percussion. By percussion, (1) sounds are elicited, (2) the degree of 
resistance to the percussing finger estimated. When a part is percussed 
the sounds produced are noises or tones. If a tone, the vibrations are 
uniform and will vibrate in unison with a tuning-fork ; if a noise, the 
vibrations produced are without uniformity. We distinguish the 
sounds by certain characters. They are the pitch, the volume, the 
duration, and the quality of the sound. The pitch depends upon the 
rapidity of vibrations, hence the number that occur in a definite period 
of time. It may therefore be high or low. In sounds that are high 
in pitch the vibrations are rapid. In sounds that are low in pitch the 
vibrations are correspondingly slower in the same period of time. The 
volume or intensity of the sound depends upon the amplitude of the 
vibrations, and varies directly as the square of the amplitude of vibra- 
tions. It is modified by the degree of force used in the production 
of the sound. " Duration " explains itself. These characteristics bear 
certain relationships. Sounds that are high in pitch are of diminished 
volume or intensity and of short duration. The accompanying sketch 
is diagrammatic of the relation of the characters of the sound. (See 
Fig. 46.) On the other hand, sounds that are low in pitch have corre- 



FlG. 46. 




Tympany. 



Volume and duration. 

Diagrammatic sketch of the relations of the characters of tone. The perpendicular 
line represents the pitch. The transverse line the volume and duration. 



244 



SPECIAL DIAGNOSIS. 



spondingly greater volume or intensity and longer duration. The three 
characteristics determine the quality of the sound. The term " clear- 
ness " is the quality applied to sounds which are of the character of 
tones. They are low in pitch, of good volume, and long duration. 
Sounds that are high in pitch, of small volume, and short duration, 
are of a dull quality. Noises, without pitch, volume, or duration, are 
absolutely dull or flat. The former are indicative of the presence of 
air ; the latter, of the absence of air. The tones, or clear sounds, are 
naturally produced over structures containing air. Structures in which 
the relationship of air to solid material varies yield sounds which vary 
in degree of relationship between clearness and dulness. Resonance 
and tympany are clear sounds which will be explained later. 

Method of Procedure. Due attention should be paid to the presence 
or absence of tenderness which necessarily modifies the results obtained 
by this method of exploration. Notwithstanding the presence of a 
considerable degree of tenderness, definite information can be secured 
by light percussion. In children percussion should be the final step in 
the examination. 

Immediate Percussion. The chest may be tapped by the finger or 
hand directly. This was the original method of percussing the chest, 
but is not now in vogue, except when the clavicles and surface of the 
sternum are percussed. It was known as the immediate method. 

Mediate Percussion. The method now employed is that in which a 
medium is selected to intervene between the chest wall and the instru- 
ment used for percussing. This medium is known as a pleximeter. 
It may be a small plate of ivory of suitable size to place between the 
ribs, or, better still, the fingers of the hand not used in tapping. The 
plessor is used to create the sound. It may be a small hammer. The 
one usually selected is of moderate weight, has a firm, light, slightly 
flexible handle and metal mallet, the ends of which are tipped with 
rubber. For purposes of class demonstration a plessor of this char- 
acter, with an ivory pleximeter, is of value, but for bedside work the 
fingers of the physician are the best. 

The Use of the Pleximeter. The pleximeter must be placed in close 
apposition to the surface of the chest in performing percussion. If the 
finger is used as a pleximeter, in percussing the anterior portion of the 
chest, for instance, it must be placed parallel with the ribs. It must 
not cross them. If it is not in close apposition to the chest the cushions 
of air between the two will modify the sound so that accurate data are 
not obtained. Interspace after interspace should be percussed in this 
manner from above downward. At the same time, if necesssary, the 
pleximeter may be placed over the corresponding ribs, but parallel 
with them. With a little practice the method of applying the plexi- 
meter can soon be acquired. 

The Use of the Plessor. This requires considerable practice on the 
part of the student. If a metal instrument is used care should be 
taken to acquire the habit of percussing under all circumstances 
with the same degree of force. If the hand of the operator is em- 
ployed as a plessor several acts in the procedure must be remembered. 
It is better to select one finger, and preferably the middle finger of the 



DISEASES OF THE LUNGS AND PLEURJ1. 245 



hand used. Some operators use more than one finger, but with a little 
practice a sufficient degree of force can be given with one to elicit the 
sounds essential for distinction. The finger should be bent at right 
angles and kept in a fixed position. It must be made to strike the plex- 
imeter directly perpendicularly to its plane. If the blow is given other 
than at a right angle to the part percussed a true sound cannot be 
obtained. The blows must be made regularly aud the force be even. 
The character of the part investigated will determine the degree of force 
that should be used. The force of the blow is to come from the wrist 
alone. Neither the arm nor the forearm must be employed in its crea- 
tion. Beginning anteriorly with the supra-clavicular fossae and pro- 
ceeding downward an interspace at a time, comparison should be made 
with the other side at each step. The axillary portions, and the pos- 
terior portions from supra-spinous fossae to base, should then be exam- 
ined in this way. Recapitulation: Apply the pleximeter in close appo- 
sition to the surface parallel with the ribs or interspaces. Do not 
apply over rib and interspace at the same time. Strike first with one 
finger, which is bent at a direct right angle. Let it fall perpendicu- 
larly on the pleximeter. Let the blows be of equal force and in 
rhythmical succession. Let the force of the blow be created by the 
wrist. Always compare the two sides of the chest, aud first percuss the 
side presumably normal. The arm certainly, and the forearm as much 
as compatible with wrist movement, should be kept fixed. 

Position of the Patient. The best position is the standing one, with 
the arms allowed to drop loosely at the sides, the head straight, not 
thrown back, and the shoulders allowed to fall a little forward if they 
are inclined to do so. Any position which throws the chest muscles 
into contraction helps to defeat the object of the examiner who seeks 
to elicit the chest sounds. In percussing the posterior portions of the 
chest it is desirable to have the patient stoop forward with arms folded. 
While this renders the muscles more tense, it is of advantage in expos- 
ing a larger portion of the chest. 

When the patient is confined to bed he should, if not too ill, be 
allowed to sit up during percussion, as contact with the bed or with 
pillows deadens the sounds elicited. This fact should be borne in 
mind when from any cause it is not desirable to have the patient 
sit up. 

All clothing should be removed, if possible. A thin undershirt may 
be permitted from motives of delicacy, or parts only of the chest be 
exposed at one time if there be danger of chill. 

The Sounds in Health. Three types of sound may be produced 
by percussing over the healthy thorax for the purpose of study. 1. 
Tympany over the trachea. 2. Resonance over the lungs. 3. Dulness 
over the heart. Modifications of these types represent all sounds pro- 
duced under every variety of circumstances. They will be considered 
in the order of their importance. The term resonance is applied to 
the clear sound that is produced over the chest on percussion. It is 
due to the vibration of the chest walls and of the air in the bronchi. 
"Pulmonary resonance" is a term also used to indicate the same sound. 
While as stated above the sound produced is called a tone, yet on 



246 



SPECIAL DIAGNOSIS. 



account of the relation of the air to the solid structure of the lung, 
confined in innumerable sacs, a true tone is not produced, i. e., it can- 
not be pitched with another tone or made to vibrate in unison with one. 
For practical purposes, however, the term " tone " may be used con- 
vertible with " clearnesss" and " resonance.' 7 Its characteristics caunot 
be defined accurately, and must be learned by repeated practice. 

Modifications in Health. The degree of clearness or resonance differs 
in various parts of the thorax. It is purer in the upper axillary 
region, at the angle of the scapula behind, aud on the anterior surface 
of the chest, in the second interspace. It is slightly higher in pitch at 
the right than at the left apex. It is modified by the condition of the 
chest walls. Thick chest walls, accumulations of fat, the mammary 
gland, and the scapulae impair the resonance and require deep percus- 
sion. In persons with thin walls the resonance is clear and more pro- 
nounced. The elasticity of the chest walls also modifies it. In the 
aged it is less clear because of rigid chest walls. In children, in whom 
the chest walls are elastic, the resonance is much fuller or clearer and 
approaches more nearly the character of a tone. The sounds vary 
within certain limits in different individuals with perfectly healthy nor- 
mal chests, as may be seen from the above. Moreover, a sound normal 
in one part of the chest may in another part indicate disease. It follows 
that percussion sounds do not have an absolute value ; their significance 
depends upon the individual and upon the part of the chest examined. 
The student should learn from the outset to compare the sounds devel- 
oped by percussion of symmetrical portions of the chest, and thus de- 
termine the normal for the individual. Below the third rib on the left 
side the dulness of the heart destroys the value of comparative percus- 
sion. Significance : Excess of clearness or resonance or hyper-resonance 
means excess of air, as in vicarious emphysema. Diminution of clear- 
ness means diminution of air — increase of solid structure. 

Abnormal changes in resonance caused by disease will be considered 
further. 

Dulness. The sound over the heart is dull and may be useful to 
compare Avith dull sounds yielded over areas usually resonant. The 
character of dulness has been described : it signifies the absence of air. 

Tympany. When a single cavity with smooth w 7 alls, containing 
air, is percussed, the sound that is produced is a tone of low pitch, of 
considerable volume or intensity and of long duration. The term 
" tympany" is applied to this sound. In health it can be elicited over 
the trachea, over the stomach when it is free from food, over the large 
intestine, and at times over the small intestines. In addition to the low 
pitch and large volume, it possesses a peculiar metallic quality which is 
characteristic. It is a quality of sound with which the student should 
become familiar, for variations are characteristic of abnormal physical 
conditions in the lung and the abdomen. It must be remembered that 
tympany can be developed normally over the posterior portions of the 
lungs of infants and children. The relationship of this sound to reso- 
nance, or the sound produced on percussing the healthy lung, and to 
dulness produced over airless structures, may be appreciated by refer- 
ence to the diagram modified from Gee. (Fig. 46.) In pitch, in volume, 



DISEASES OF THE LUNGS AND PLBURJ. 



247 



and in duration it is lower than resonance. The latter stands midway 
between the tympany and the dulness. As intimated previously, all 
varieties of sounds that may be produced and which occupy positions 
between the extremes noted in the triangle are dependent entirely upon 
the relationship of air to solid material. The larger bulk of air yields 
tympany. 

The Pitch. The estimation of the pitch of the sound is of the high- 
est importance. It is one distinctive attribute or characteristic which is 
of special diagnostic significance as to the physical condition of the part. 
It requires considerable cultivation by practice to estimate it. Its sig- 
nificance in relation to dulness and tympany have been mentioned. 
Although a high-pitched sound may be considered a dull sound, this is 
not necessarily so. A sound of high pitch need not be markedly dull, 
indeed it may be moderately clear. Under the right clavicle in health 
the pitch is higher than under the left, but not dull in character. 

The student may become familiar with the pitch and with alterations 
in it by percussing over a portion of the lung clearly resonant, as in the 
third interspace and thence downward on the right side. As the inter- 
spaces in apposition to the liver are reached the pitch changes. 
The fulness of the sound is lessened ; it becomes more shallow. The 
rapidity of the vibrations can almost be appreciated, and, as they 
increase, the heightened pitch caused thereby is recognized. This 
normal increase in pitch is due to a thin layer of lung backed up behind 
by the solid liver. Change in pitch makes it possible to outline organs 
and pursue topographical percussion. 

The Degree of Resistance. This is estimated by the sense of 
touch. When organs containing air are percussed the sense of resistance 
appreciated by the finger that is percussed is small, or, indeed, may be 
said to be absent entirely. The sensation to the finger is as if the parts 
underneath bounded away. When there is lessened amount of air, 
and hence more and more of an approach to solid structure, resistance 
is appreciated. It is of the greatest importance to carefully educate the 
finger to an estimation of this sense. Often it may be difficult to deter- 
mine exactly the pitch. Detection of the presence or absence of solid 
structure can be materially aided by the sense of resistance. 

Superficial and Deep Percussion. In superficial percussion the blows 
are directed lightly over the part percussed. By this manner the sound 
yielded by the portion directly underneath the hand is elicited. It is 
for this reason of advantage in percussing over portions of the lung 
that are thin. Light percussion is also necessary in children and in 
patients with sore chest walls. It must be employed if the subject has 
just had a hemorrhage. In deep percussion the blows are given with 
great force. It brings out the sound of structures situated deeply in 
the lung or w 7 hen overlapped by the edges of the lung. It is there- 
fore necessary in cases of deep-seated consolidation ; in cases of aneurism 
that is covered by luug, in order to define its limits, and particularly in 
order to determine the true height of the liver and the relative area 
of dulness of the heart. 

Auscultatory or Stethoscopic Percussion is a valuable means of pre- 
cisely defining the limitation of a dull area, as an aneurism or tumor 



248 



SPECIAL DIAGNOSIS. 



within the chest, or of determining the limits of organs even of similar 
physical structure. The stethoscope is placed over the organ the border 
of which is to be defined, and percussion is begun some distance from it. 
It is conducted toward the stethoscope, and very much sooner than by 
ordinary methods the dull sound of the non-resonant structure is trans- 
mitted to the ear. If the tympany of the stomach is to be distin- 
guished from the tympany of the colon, place the stethoscope over 
either one of the organs. Percuss with the finger-tips directly on the 
surface by immediate percussion. Begin at the stethoscope, and per- 
cuss from it. As soon as the limit of the structure percussed is 
reached a difference of tone or pitch is observed which cannot be 
detected by other means. Mediate percussion may also be employed. 

Object of Percussion. The object of percussion is to estimate the 
proportion of air contained in the chest to the solid tissue. We can thus 
determine (1) the size of the lungs ; (2) the presence or absence of abnor- 
mal sounds by which the physical condition of the part is ascertained ; 
and (3) the size of the other organs in the thorax (topographical per- 
cussion), and in the case of the abdomen the position and size of its 
organs, and the presence of tumors or other solid structures. The size 
of the lungs. Increase in size : The boundaries of the lung have been 
described previously. If the resonance extends beyond these bound- 
aries it may be said that the lungs are enlarged. This is seen in 
emphysema. The area of resonance in this affection extends beyond 
the clavicles to a greater height than in health. It encroaches upon, 
and may cause to disappear entirely, the normal area of cardiac dulness ; 
it extends one and a half to two inches beyond the lower margins in 
health. The upper border of liver dulness is therefore lower — instead 
of beginning in the fifth or sixth interspace it begins an inch or two 
below. Diminution in size : Shrinkage of the apices (one or both) 
takes place in phthisis, hence the resonance of health does not extend 
as high up in the neck. Shrinkage or contraction may take place along 
the lateral borders or lower edges on account of phthisis or retracting 
pleurisy, causing diminution in size of the lung and spurious enlargement 
of the heart or liver. In diseases below the diaphragm, effusion or 
large liver, the size varies. The area of the dulness due to the size of 
the heart and the liver, by which the size of these organs is estimated, 
are considered under methods of examination of the respective systems. 

The Sounds in Disease. It may be said in general that when 
a sound is produced over the thorax which does not correspond with 
the normal resonant tone, it indicates an abnormal physical condition, 
or disease. Difference in the percussion note of two exactly correspond- 
ing portions of the chest almost always indicates some abnormality. 

Change in tone may be general or local. The areas over both lungs 
may yield a different percussion note from the normal (bilateral) ; the 
change may be limited to one side (unilateral) ; or it may be found in 
small areas (local). 

Increased Resonance. The resonance may be increased or diminished. 
When the resonance is increased the sound is abnormally clear'. If it 
is fuller and clearer than in health, but does not possess the charac- 
teristics of the tympanitic note, it is known as hyper-resonance or exag- 



DISEASES OF THE LUNGS AND PLEURJ. 



249 



gerated resonance. The physical condition which causes exaggerated or 
hyper-resonance is increase in the amount of air. This increased amount 
of air may be general, unilateral, or local. When general {bilateral) it 
gives the characteristic sound heard in emphysema. At the same time 
dull areas are encroached upon. The heart dulness is effaced, the liver 
duluess lowered. In this affection the amount of air is so great and the 
tension of the chest walls so exaggerated that hyper-resonance and some- 
times a pure tympanitic sound (" band-box' 7 resonance) is produced over 
the entire thorax. The same increased resonance may be present in 
acute miliary tuberculosis. Unilateral increase in resonance or tympany 
occurs when there is an increased amount of air in one lung, on account 
of compensatory enlargement (vicarious or compensatory emphysema), 
or on account of an increase of air in the pleura. Local increase of 
resonance occurs when a local area of the lung is acting in a compen- 
satory manner. This is seen in cases of phthisis in which the alveoli or 
lobules surrounding small areas of consolidation are very distended. The 
exaggerated note may aid in the recognition of a deep consolidated area. 
The same note, hyper-resonance, is obtained over a portion of the lung 
above the line of pleural effusion and above the line of consolidation in 
pneumonia. 

Fig. 47. Fig. 48. 




Diagram showing at x moderate dulness Diagram showing heightening of pitch an- 
over tubercular infiltration. (Gibson and teriorly at x from consolidation posteriorly 
Russell.) (shaded points). (Gibson and Russell.) 

Diminished or Impaired Resonance. The normal tone or resonance is 
impaired — that is, the pitch is higher, the volume is less, and the dura- 
tion is shortened — in cases of commencing consolidation of the lung, and 
in small pleural effusions in which the layer is thin. It is the first 
change toward dulness, and is particularly noted in the early stages of 
phthisis. The lung area, usually the apex, is the seat of small areas of 
tuberculous infiltration. The relative amount of air to solid structure 
is lessened. Impaired resonance is the result. As the disease advances 
the note changes gradually to dulness. 

Pitch. Gibson and Russell have pointed out the change in quality 
of sound with change in pitch. (See Fig. 48.) If, for instance, the apex 
of the lung is percussed in front, and at the same time there is an 



250 



SPECIAL DIAGNOSIS. 



effusion of fluid behind, or a consolidation of small area directly on the 
opposite surface of the lung, the pitch of the sound is raised, when com- 
pared with the sound in the opposite lung at the corresponding point. 
A clear sound of heightened pitch is diagnostic of airless structure 
behind air-containing structure. 

Tympany in Disease. Significance : If a tympanitic note is elicited 
over a part where in health resonance should be found, it is an indica- 
tion of disease. It signifies (1) that air is confined in a space (cavity), 
or an excess of air in many sacs, as the lungs in emphysema ; (2) that 
the tension of the lungs is less than normal — the lung is relaxed, as it is 
above the limits of a pleural effusion. The issue of a tympanitic sound 
from the chest occurs — 1. As previously stated, bilaterally, in cases ot 
emphysema. 2. Unilaterally, in cases of pneumothorax and compensa- 
tory emphysema. In pneumothorax the pitch may be raised if there is 
much tension. It is then known as dull tympany. 3. Locally. It is 
limited to the lobe of the lung in some cases of compensatory emphy- 
sema. It may occur in the early stage of pneumonia, or in the later 
stage of complete consolidation. In the former it is due to relaxed ten- 
sion ; in the latter, to the air in the bronchus the lumen of which 
is free. In cases of pleural effusion, owing to alteration in the tension 

of the lung, a tympanitic note is present above 
the layer of fluid. In phthisical excavations 
at the base or the apex, and in bronchial dila- 
tation, if the cavity communicates with the air, 
and has moderately thin, elastic walls, and at 
the same time is empty, a tympanitic note is 
produced. The musical pitch of the note de- 
pends upon the volume of air, the size of the 
opening, and tension of the wall. Large vol- 
ume of air, low pitch; large opening, low 
pitch ; greater tension, higher pitch. Small 
volume, high pitch ; small opening, high pitch ; 
less tension, low pitch. (For modifications of 
tympany see Special Sounds, and Cavities.) 

Dulness in Disease. The note is high in 
pitch, small in volume, and short in duration. 
Absence of air, or a relatively small amount 
in proportion to solid structure, is present. 
The conditions which give rise to it are all 
forms of consolidation and pleural effusions. 
The extent and the degree of dulness depend 
upon the proportionate amount of solid to air- 
containing material. Moderate dulness is seen 
in tubercular disease with moderate infiltration 
of the lung (see Fig. 47), and in small patches 
of catarrhal pneumonia, in pulmonary conges- 
tion, and in atelectasis and physical conditions 
in which there is solid material in greater proportion than in health. 
Absolute dulness occurs when the air is completely absent, as in the 
stage of hepatization of acute pneumonia, in hemorrhagic infarction, in 





At the apex complete dulness 
and bronchial breathing, from 
tuberculous consolidation ; in 
the middle portion impaired 
resonance, from disseminated 
tubercles ; below exaggerated 
resonance, from compensatory 
emphysema. 



DISEASES OF THE LUNGS AND PLEURJ. 



251 



condensation from pressure, in pleurisy with large effusion, or great 
thickness of the pleura, and in tumors. Flatness is applied to the 
extreme degree of dulness. (See Fig. 49.) 

We have, therefore, all gradations of the dull sound, from simple 
impaired resonance in incipient tuberculosis of an apex of the lung, as 
determined by careful comparison of the two apices, to absolute flatness 
or deadness. Method of percussion : The kind of percussion necessary 
to bring out the dulness will depend upon its extent and distance from 
the surface. When the consolidation or thickening is superficial, possi- 
bly lying against a thickened pleura, light percussion will discover it, 
whereas strong percussion would bring out the resonance of the deeper 
healthy lung tissue to such an extent as to mask completely the super- 
ficial dulness. On the other hand, when the airless consolidated tissue is 
deep-seated and surrounded by healthy lung, strong percussion is required 
to discover it. 



Fig. 50. 




Pneumothorax ; resonance over retracted lung. Tympany over air. Dulness or 
flatness over fluid. (Gibson and Eussell.) 

Again, when the airless tissue occupies a small focus and is surrounded 
by healthy lung, as in pneumonia beginning centrally, and when there 
are small airless foci, as occur sometimes in disseminated tuberculosis, 
percussion is often wholly negative. 

Special Sounds. Special percussion sounds, or sounds the quality of 
which differs from the ordinary tympanitic sound, are present in some 
physical conditions. Of these the amphoric, or metallic, and the cracked- 
pot percussion sounds are most familiar. The amphoric sound is tym- 
panitic, but has a metallic clang, or echo. The prolongation of the 
sound is compared to an echo. It is like the sonorousness or ring of the 
voice when one speaks in an empty hall. It can be imitated by percus- 
sing an empty vessel. It is heard best in cases of pneumothorax (see 
Fig. 50) and in phthisical excavation when the cavity is large, is 
superficial, with smooth walls, and when it has open communication with 
a bronchus. The cracked-pot sound, as the name indicates, resembles 
that produced when a cracked vessel is tapped ; is it simulated by 
clasping the hands loosely at right angles to each other and striking 



252 



SPECIAL DIAGNOSIS. 



them over the knee. It is heard best over cavities which communicate 
directly with a bronchus, especially if the chest wall is thin and yields 
to the percussion stroke. The cavity is usually at the apex. In order 
to elicit the sound the patient should keep the mouth open. The sound 
should be created at the time of expiration, and the percussing finger 
should be retained instead of elevated after striking the pleximeter. In 
some rare cases this sound can be elicited in health. The other patho- 
logical changes with which the sound occurs are in pleurisy above the 
effusion, pneumonia before consolidation has taken place, and in pneu- 
mothorax, if there is a free communication between the cavity and a 
bronchus. In the latter instance, the sudden rush of air into the bronchus 
produces this sound. This is proven by the fact that it can be created 
when the chest is percussed in a case of empyema after the fluid has been 
evacuated by a free incision. It is to be noted that, while corroborative 
evidence, it is not alone positive evidence of any single condition. 

Auscultation. In the act of breathing sounds are produced. They 
are heard by the application of the ear directly or through some medium 
to the chest. They are created both in inspiration and in expiration. 
They vary in character in accordance with the situation. Method. The 
patient if possible should sit up in an easy unrestrained position. For 
auscultation in front the arms should hang carelessly by the side. 
The breathing should not be forced. (See page 258). To auscultate 
behind the patient should fold the arms and lean slightly forward. For 
comparison both sides should have the same freedom of movement, which 
would not be attained if the patient occupied a lateral or side position. 

Auscultation is practised by two methods : First, a thin towel free 
from starch, or a napkin, alone intervening, the ear is applied directly to 
the chest. This is known as the immediate or direct method. It is of 
service to ascertain the character of the sounds in general. It has the 
disadvantage of imperfect localization of them. Second, by means of 
the instrument known as the stethoscope the mediate or indirect method 
is practised, but is disadvantageous in infants because the infant cannot 
be kept quiet or is sensitive to its pressure, and in children because 
instruments are alarming. 

The advantages of the stethoscope over direct methods of ausculta- 
tion are seen when it is necessary to localize sounds. The definite 
localized area in which the sound is produced can be ascertained, and 
sounds in close proximity differentiated. Its use is essential in the 
study of heart sounds. In addition the operator is more likely to 
escape from contagious diseases and vermin. Moreover, on the score of 
delicacy, the stethoscope is preferable. 

The stethoscopes that are used are the single and double, and they vary 
in form with the practice of the operator. It should be an absolute rule 
with the student that he should become familiar with and use one form 
of stethoscope alone. The single stethoscope is very good to localize 
and determine the relation of sounds. It also transmits the shock of an 
aneurismal vessel or of the heart. The objection to it is that it causes 
pain if the chest is sore, from the weight of the head, and the pressure 
of the instrument may modify sounds if bloodvessels are auscultated, or 
sounds in close proximity to the ear, as a friction. In the use of the 



DISEASES OF THE LUNGS AND PLEURA, 



253 



single stethoscope the student should be particular first to see that the 
portion applied to the chest is perpendicular to the plane of the area 
over which auscultation is practised. Otherwise slight tilting of the 
instrument will take place and outside noises be transmitted through 
the tube. The operator should place himself in an unconstrained posi- 
tion and see that his head is accommodated to the position of the instru- 
ment, not the latter to the head. The ear-pieces should fit comfortably. 
If the parts are covered with hair an extraneous sound from friction is 
produced. Oil should be applied to allay this. The double stethoscope 
is the most suitable when the patient is made use of for the instruction 
of classes. It can even be applied over parts that are quite tender. 
The rule of application to the chest is the same as that of the single 
stethoscope. The humming sound in the tube is confusing at first. 

The Sounds in Health. If the stethoscope is placed over the trachea 
at the top of the sternum a sound characterized as follows will be heard : 
First, it attends inspiration and expiration with a definite pause be- 
tween ; second, the inspiration and expiration are equal in length ; 
third, they are of a soft, blowing character. The inspiration is per- 
haps a little stronger than the expiration. If the mouth is closed there 
is no change except that both inspiration and expiratiou are harsher 
and sharper. Bronchial breathing is the term applied to the sound 
which is heard in this situation. It is one of the normal sounds of the 
chest. It may be heard behind, at or a little below the seventh cer- 
vical vertebra, feebler in quality than in the trachea, and in the inter- 
scapular space over the large bronchi as they leave the trachea. A 
sound heard in these areas, bronchial in character, is normal. 

Vesicular Breathing, or the Respiratory Murmur. If the ear is 
^ applied over the anterior portion of the chest, or better still, in the 
upper axilla or below the angle of the scapula behind, a sound is heard 
both on inspiration and expiration. It differs from bronchial breath- 
ing, however, in that inspiration and expiration are changed in length. 
The inspiration is one-third longer than expiration. The sound of 
inspiration is soft, breezy, or sighing in character, increasing in intensity 
to the end of full inspiration. It is immediately followed by expiration, 
which diminishes in intensity as the air is expelled, and terminates when 
two-thirds of the expiratory act is completed. The sounds can be imitated 
by breathing with the lips in position required to articulate " f " or " v." 

Cause of the Sounds. The sound is caused by the passage of air 
through the nares into the wider pharynx when the mouth is closed. 
The sounds heard over the bronchi, the terminal bronchioles, and 
the vesicles are probably created in the upper air-passages and trans- 
mitted to the ear through the medium of the bronchi. Bronchial 
breathing is the sound unmodified, transmitted to the ear, weakened only 
by its distance from the upper air-passages. The vesicular breath-sound 
is the same sound modified ou account of the intervention of the air 
vesicles between the ear and the larger bronchi. The sound is thus 
smothered or dampened down. It was held that part of the sound of 
vesicular breathing, if not the whole, is due to expansion of the vesicles 
and rush of air through the bronchioles. The proof, however, seems 
to be in favor of the first view given, chiefly because, when the vesicular 



254 SPECIAL DIAGNOSIS. 

tissue is removed, as in pneumonia or other consolidation, even far dis- 
tant from the trachea, bronchial breathing is produced. 

Modifications oj the Sound in Health. Exaggerated Breath-sounds. 
Bronchial breathing and vesicular breath-sounds are increased in loud- 
ness and sharpness by strong, rapid breathing. In certain places 
within the bounds of health a sound is heard which partakes of the 
qualities of both bronchial breathing and the vesicular sound. It is 
particularly noticed in the inter-scapular region about the level of the 
spines of the scapula in individuals in whom, in this situation, pure 
bronchial breathing is not heard. Its characters are, first, soft, blowing 
inspiration, or loud, harsh inspiration ; second, slightly prolonged expira- 
tion, more exaggerated, louder, but not harsher, than in health. The term 
broncho-vesicular is applied to this kind of breathing. It is due to the fact 
that the sound produced in the larynx is conducted to the ear less damp- 
ened down or modified because of the smaller number of air-vesicles which 
surround the bronchus than are found in the remainder of the lung. 

The sounds are increased in children, in whom there is combined 
greater elasticity of the chest wall and greater friction throughout the 
smaller bronchi, which are relatively larger. So distinct and character- 
istic is the sound in children that the term puerile respiration is applied 
to it. The sounds of inspiration and expiration are both intensified or 
sharper than in health; the latter is relatively prolonged. 

Feeble Breath-sounds. The sounds are modified by the condition of the 
chest walls. If they are thick, or there is an abundance of fat, the sounds 
are fainter or lessened in intensity. Feeble respiratory power, in wast- 
ing and exhausting diseases, causes feeble breath-sounds. The condition 
of the upper air-passages, even if not pathological, modifies the sounds. 
If the glottis is small, or there is a disturbed relationship between the nose 
and pharynx, the sounds will be modified. They are usually weakened. 

The Sounds in Disease. Before indicating the sounds which 
arise from changes in the physical condition of the lung, it may be 
well to call attention to the confusion that always arises when the 
student is examining the chest for the first time. The probability is 
that the coincidence of heart and lung sounds in the chest prevents the 
detection of the respiratory sounds. If attention is paid to the rhythm, 
they can be distinctly isolated. At the same time that the student is 
auscultating the lungs, the hand should be placed on the thorax or the 
epigastrium and attention fixed upon the two acts of respiration — in- 
spiration and expiration. Before attempting to time the breathing, note 
the occurrence of each movement, the expansion of inspiration and the 
contraction of expiration, and then note the character of the sound that 
is heard in each. By this meaus the sounds of respiration are accurately 
ascertained, and confusing extraneous sounds, as from the heart, distinctly 
eliminated. It is well for the student to bear in mind that sounds heard 
in the chest, which are departures from the normal sounds, always indi- 
cate disease. 

Vesicular Breathing Exaggerated. Bilateral. The vesicular breath- 
ing or respiratory murmur is increased, first, when there is increase in 
the force of breathing — when normal respiration is increased and the 
patient takes full, deep breaths. It is seen in some forms of dyspnoea, 



DISEASES OF THE LUNGS AND PLEURA. 



255 



as in the acme of Cheyne-Stokes breathing or in the dyspnoea of diabetic 
coma. It may be increased or exaggerated in certain forms of bron- 
chitis, particularly when the small tubes are narrowed. Unilateral ex- 
aggeration or increase of vesicular breathing is heard when the lung is 
acting vigorously, or in a compensatory manner. The strong inspira- 
tion followed by strong and relatively prolonged expiration of an 
actively moving lung signifies almost certainly disease of the luug of 
the opposite side. Local exaggeration of vesicular breathing, the in- 
spiration harsh, is noted iu cases of phthisis in its earliest stages. It 
should be compared with the sound of the opposite side, when the dis- 
tinction can easily be ascertained. It is heard over the apex, in pneu- 
monia or pleurisy of the base, and vice versa. 

Vesicular Breathing Diminished or Absent. Anything which lessens 
the amount of air supplied to the chest diminishes the vesicular breath- 
ing. Bilateral. It is, therefore, lessened in cases of occlusion or ob- 
struction of the nares, the pharynx, or the larynx. It is lessened in 
all cases in which the expansion is interfered with. In feeble per- 
sons the respiratory murmur is particularly weak behind. If the 
muscles of respiration are paralyzed or enfeebled, the murmur is also 
lessened. If the expansion is interfered with on account of disease 
of the diaphragm or pressure upward by accumulations in the abdo- 
men, it is weakened. Thickened chest walls that occur from disease, 
as oedema, weaken the respiratory sound. The vesicular breathing is 
weakened throughout the entire extent of the lung in emphysema ; on 
account of the enfeeblement of respiratory forces and shortening of the 
act of inspiration, less air enters the already over-full chest ; moreover, 
in the bronchitis that attends emphysema, the bronchioles are all 
more or less occluded, and hence the air supply lessened. (See Fig. 
35.) Unilateral diminution of breath-sounds occurs (1) when there 
is narrowing of the bronchus as in cases of aneurism or mediastinal 
tumor ; (2) when there is pleural effusion, which (a) lessens the amount 
of air-space by compression of the lung and (b) interferes as a different 
conducting medium. (Fig. 50.) If pain in pleurisy, pleurodynia, or 
neuralgia is present on one side, the breath-sounds of the affected side 
will be lessened. Not only in pleural effusions from serum, blood, pus, 
or air, but also in thickness of the pleura there is weakness or faintness 
of the respiratory murmur. It should not be forgotten that effusions 
and thickenings of the pleura rarely take place bilaterally; under 
these circumstances the breath-sounds would be weakened. The degree 
of enfeeblement is not so great as it is when effusion is limited to one 
side. Local diminution of breath-sounds occurs in the early stage of 
phthisis or in the earliest stage of pneumonia. 

It is well for the student to analyze the sounds and attend closely to 
their character during each event of a respiratory act. Having fixed the 
attention on respiration, noted its divisions and excluded cardiac rhythm, 
note (1) the character of the sound in inspiration ; (2) the character of 
the sound in expiration ; (3) the relative rhythm or length of the two. 

Alteration of the Rhythm. In addition to the character of the breath- 
sounds, we take cognizance of the rhythm of the sounds. In health the 
movement of inspiration and that of expiration are almost equal, but, as 



256 



SPECIAL DIAGNOSIS. 



previously noted, the sound of inspiration is heard during the entire 
act, while that of expiration occupies the first third or so of the act. 
The sound produced during expiration may even be less than half the 
length of inspiration. The following proportion represents relative 
length— I : E : : 3 : 1. 

Expiration Prolonged. The first notable change in respiration, the 
vesicular murmur remaining normal, is prolongation. When the ex- 
piration is prolonged it equals inspiration, or may even be longer. 
This is due to difficulty in getting the air out of the chest — expiratory 
dyspnoea, a physical condition by which the sound of expiration is con- 
ducted to the ear. It is prolonged in bilateral broncho- vesicular breath- 
ing (q. v.). Prolongation of expiration all over the chest is seen in 
emphysema. The inspiration is short, the expiration prolonged. Al- 
though distinct throughout the chest, it is more pronounced above the 
clavicles and along the free margins of the lung anteriorly. Local 
prolongation of the expiration is of great diagnostic significance when 
areas of the lung are consolidated in part and the elasticity thereby im- 
paired. The respiratory murmur is harsh, or puerile, or it may be 
weak. This condition obtains in tuberculosis and is one of the first 
physical signs of this affection. 

Jerking or Interrupted Inspiration. Instead of the smooth, even, 
sighing, or breezy inspiration the sound is created in puffs or jerks, 
so that during the act of inspiration, as the chest expands, a number of 
successive vesicular sounds are heard until the act is completed. The 
physical condition which causes jerking inspiration, or cog-wheel breath- 
ing, is found in the earlier stages of tuberculosis, when the various 
bronchioles are more or less occluded by outgrowths of tubercle. The air 
therefore enters different lobules at different periods of time, and on ac- 
count of breaks taking place, we have the occurrence of this peculiar irreg- 
ular sound. It must not be confounded with the same character of 
breathing that is heard adjacent to the heart, due to the pressure of that 
orgau, or of structures in intimate relation therewith, upon portions of 
the lung, on account of which air enters various areas in puffs. On 
the other hand, jerking inspiration sometimes occurs in health. It is 
heard in nervous patients. While due to the physical conditions men- 
tioned, it is of no significance unless attended by other physical signs. 

In cases of adhesions at the apex, particularly of the left lung, the 
same puffing or jerking inspiration is often heard. It is also present 
in aneurism, or disease of the aorta, pressing upon a bronchus on account 
of which the air enters the part in an intermittent manner. When 
pathological jerking breathing is present the expiration is prolonged, 
and if the case is under observation a sufficiently long time, bronchial 
breathing will usually replace the respiratory murmur. Small, moist 
rales usually attend jerking breathing when it is pathological, especially 
if excited by coughing or a full breath. 

Bronchial Breathing. The normal situation of bronchial breathing 
in health has been indicated. If the same kind of breathing is heard 
in any other portion of the lung, it is pathological. It is generally 
indicative of the presence of consolidation. The spongy lung-tissue is 
replaced by solid conducting material, by which the bronchial sound 



DISEASES OF THE LUNGS AND PLEUEJ. 



257 



is conducted to the ear. It is heard, therefore, in all pathological con- 
ditions in which consolidation takes place. It is the typical form of 
breathing of pneumonia (see Fig. 51), of consolidation of the lung due 
to tuberculosis, of hemorrhagic infarcts, and of syphilis. It must not 
be forgotten, however, that cases of pneumonia do exist without this 
type of breathing. This is the case when the large bronchus supplying 
the lungs, or the bronchioles, are occluded by inflammatory exudate. 
In tuberculous consolidation it may be absent for similar reasons. In 
central pneumonia, where consolidation is deeply seated and surrounded 
by lung-tissue, bronchial breathing may not be heard, or it may be 
postponed until the third or fourth day of the disease, by which time 
consolidation has reached the surface of the lung. In certain cases of 
pleurisy with effusion, bronchial breathing exists. The affection is 



Fig. 51. 




Cavity with cavernous breathing 
and gurgling rales 




Showing phthisis at various stages. (Gibson and Russell.) 



not great enough to compress the lung completely. The bronchial 
tubes remain patent, while the vesicular structure is compressed. A 
low-pitched bronchial breathing is heard under these circumstances. It 
is more pronounced at the upper layer of the effusion. It is always 
heard close to the spine posteriorly, where the lung is compressed. 
Sometimes it is heard above the limit of the effusion, in all probability 
because of relaxed tension of the lung. 

Varieties of Bronchial Breathing. All their characteristics must be 
borne in mind. (See p. 253.) It must not be forgotten that bronchial 
breathing is not represented accurately in every instance by the sounds 
heard over the trachea. Its character may be modified and yet ap- 
proach the type of breathing heard at that place. The modification 
occurs in any one of the two portions that go to make up the sound : 
(1) The blowing element may not be as distinct in inspiration as in 
expiration ; (2) in rare cases the characteristic blowing sound may not 
continue as long during expiration as to equal the inspiratory sound. 

17 



258 



SPECIAL DIAGNOSIS. 



On the other hand, (3) the bronchial breathing may vary in pitch. At 
times it is heard in abnormal states (a) high in pitch, both in inspira- 
tion and expiration, but with a pure blowing quality (harsh) attending 
each. It may be (6) soft and low in pitch attending both acts. The 
strong, high-pitched sound emitted by breathing deeply when the lips 
and tongue are placed in position to pronounce "ch" is termed tubular 
breathing. It is the characteristic sound of croupous pneumonia. 
(4) The loudness of the sound may also vary. This depends largely 
upon physical peculiarities of the individual. The condition of the 
chest w r alls and the force of breathing determine it. 

When pleurisy with effusion coexists with pneumonia, the bronchial 
breathing, which should be audible, is feeble and distant. Under the 
same circumstances a bleating sound is heard. (See ^Egophony.) 

Mode of Determination. Breathing which may, during very quiet 
respiration, appear to -be normal, is sometimes discovered to be bronchial 
when the patient has a spell of coughing and then takes several deeper 
breaths than usual in rather quick succession. Sometimes the noise made 
in nasal respiration obscures the pulmonary sounds. The patient should 
be instructed to breathe with the mouth open, to take somewhat deeper 
breaths than usual, and to let expiration follow at once upon the close of 
inspiration. Many patients when told to take deep breaths expand their 
lungs to the utmost, and then hold the air in awhile, and allow it to pass 
out slowly. Such a method usually defeats the purpose of the examiner, 
which is first to note the relative length of inspiration and expiration, 
and then the quality of the two sounds, first, as regards each other, and, 
secondly, as compared with the normal. In listening for bronchial 
breathing the attention should be fixed more upon the length and 
quality of the expiratory sound, and therefore it is important that 
the patient breathe so as to bring out most clearly its characteristics ; 
this he can do generally by taking several moderately deep breaths in 
quick succession and with the mouth open. 

Modifications of Bronchial Breathing. If a case of tuberculous con- 
solidation is watched, it will be found after a time that the bronchial 
breathing becomes lower in pitch. It is heard in inspiration and ex- 
piration, but a more hollow quality attends the sound. From the 
hollowness of the tone the term cavernous has been applied to the 
breath-sound, and the change in the part that has taken place to cause 
it is due to obstruction or excavation of the consolidation, or to dilated 
bronchi. It is a sign of a cavity (see Fig. 51). Cavernous breathing 
may have a metallic quality attending it, and then it is called amphoric. 
It is analogous to the sound produced by blowing across the open mouth 
of ajar. A large cavity with smooth walls that communicates with the 
air is the cause of the development of such sound. It is heard also in 
pneumothorax, when such communication exists. The metallic tone 
is analogous to the metallic percussion sound. It occurs under the 
same physical circumstances. The physical condition which causes it 
may be so marked that the same character of tone is imparted to rales 
produced in the cavity, or to the heart sounds which are transmitted 
by the solidified area surrounding the excavation. 

Broncho-vesicular Breathing in Disease. The physical condition is 



DISEASES OF THE LUNGS AND PLEURA. 



259 



commencing consolidation surrounded by vesicular structure. It is 
found midway in the change from respiratory murmur to bronchial 
breathing in tuberculosis. The inspiration is harsh ; the expiration 
prolonged, harsh, and blowing ; or the former may be bronchial or cav- 
ernous, the latter absent. It may, however, be indistinct or masked 
by rales. It is heard sometimes in the earlier stages of pneumonia, and 
is the modified bronchial breathing which is heard when small areas 
are consolidated in capillary bronchitis and catarrhal pneumonia, with 
collapse of lobules. The term "transition breathing" has been applied 
to this character of breath-sounds. 

New Sounds. The foregoing sounds are modifications of the normal 
sounds that are heard during the act of breathing. New sounds or 
adventitious sounds are created in the lungs or in the pleura. In the 
lungs the term rales is applied to them, and in the pleura they are 
known as friction sounds. Under the same head may be classified the 
succussion sound and metallic tinkling. 

Hales. Rales are sounds created in the bronchi, bronchioles and 
air- vesicles, or in pathological excavations (cavities). They are clue (1) 
to the passage of air through bronchial tubes which are narrowed, either 
on account of swelling of the mucous membrane, or on account of 
spasm ; or (2) the passage of air through fluid (mucus, serum, pus, 
blood). The term "dry rales" is applied to the former class; moist 
rales, or crepitation, to the latter. Dry rales, or rhonchi, are divided 
into (a) sonorous and (b) sibilant. The former are large rales, the 
character of which is indicated by the name. They are created in the 
large bronchial tubes. They are coarse, low-pitched musical sounds. 
The latter are created in the small tubes, and are high-pitched, whistling 
sounds. Both are heard only over the areas of their creation, although 
the sonorous rale may be transmitted all over the chest. Both may be 
heard at the same time. The dry rales are heard in the early stages of 
bronchitis, when the mucous membrane is swollen and thickened, but has 
not begun to secrete mucus or muco-purulent matter. They are also 
heard in asthma in which there is spasm of the bronchial tubes, and in 
the chronic bronchitis of emphysema. In the latter the smaller rales 
are more common. 

Moist Hales, or Crepitation. They may be divided into large or small 
rales ; the latter are also called subcrepitant. (See Fig. 51.) The crepitant 
rale is a fine rale, said to be created iu the alveoli, due to inflation of the 
cells the walls of which have held together by exudation or fluid (cedema). 
It is a fine rale distinctly localized, resembling the sound produced by 
rubbing a lock of hair between the fingers or by putting salt on a hot 
plate. In the early stage of pneumonia and in cedema of the lungs it is 
said to be pathognomonic. It, however, may be heard under all cir- 
cumstances where there is a small amount of fluid in the alveoli and 
feeble respiratory action. The small, moist, or subcrepitant rates are 
created in the smaller bronchioles and the alveoli. They may be gen- 
eral or local. If general, they are due to bronchitis in the second stage. 
There is an abundance of secretion in the terminal air-passages which 
is thrown into vibration by the current of air during the act of breath- 
ing. The element of moisture is pronounced and gives to them their 



260 



SPECIAL DIAGNOSIS. 



character, to which the term "crackling" is sometimes applied. They 
are found in congestion with outpouring and stagnation of secretion ; in 
oedema ; and whenever fluid is drawn into the bronchi, as when there 
has been a hemorrhage in the upper passages. Small moist rales in 
local areas are found in phthisis, particularly in the first stage, on account 
of the local bronchial catarrh, and in the second stage for the same reason. 
They are also heard in the early stage of pneumonia, particularly in the 
area of the lung which is the seat of collateral oedema adjacent to the 
consolidation. They are also heard in the later stages of pneumonia when 
resolution has taken place. If this is reached, however, they may be 
replaced by large rales. They may be heard around any consolidation 
because of congestion, oedema, or catarrh. It must not be forgotten 
that cough or forced inspiration must be excited before it can be said 
that rales are absent. 

Large moist rales, or mucous rales, are created in the larger bronchial 
tubes, or in cavities, from the same causes that produce them in the 
smaller tubes. The fluid, however, is larger in amount, the air-current 
stronger, and the space for vibration is greater. While heard in bron- 
chitis, in their most marked form they are heard in the third stage of 
phthisis. They are described as bubbling and gurgling rales, and they 
are very characteristic after a full breath or cough. (See Fig. 51.) 

Rales are to be distinguished from other adventitious sounds. Cer- 
tain characteristics that attend them make this easy, although over and 
over again it is quite impossible to determine whether fine rales or friction 
sounds are present. This is particularly the case when the rales are heard 
over the bases of the lung. We recognize rales, first, from the characters 
previously mentioned. Second, by their locality-, if the adventitious 
sounds are general, they are due to rabies. Third, rales are modified by 
cough or breathing. They may be intensified by either act, or, after the 
completion of the act, may disappear entirely. On quiet breathing, in 
the early stages of tuberculosis, for instance, they may not be heard at 
all. It is absolutely necessary before excluding them to have the 
patient cough and then take a full breath. Fourth, they vary in posi- 
tion. This may occur from hour to hour. If the chest is examined in 
the morning they may be more pronounced, for instauce, at the base. 
At another time 'in the twenty -four hours they are distinct at the 
apex. They are more likely to be present at the base if the patient is 
kept in the recumbent posture. Fifth, they vary in character. At one 
time small, moist rales are heard ; in a short time they are replaced by 
larger rales. Of course, the change from dry to moist rales is sure to 
take place as a pathological condition. In a case of bronchial asthma 
all sorts of rales may be heard in a few hours. Sixth, they seem to be 
farther away from the listening ear than are friction sounds. 

Rales in the bronchi must not be confounded with the crepitant or 
fine crackling sound which is heard at the base of the lung in patients 
who have been ill from the exhaustive fevers and who have not taken 
full breaths for some time They disappear after the patient has inspired 
deeply for a half dozen times. 

Rales alone are not diagnostic of any affection save bronchitis, in 
which, with the absence of other physical signs, their occurrence all 



DISEASES OF THE LUNGS AND P LEU R M . 



261 



over the chest is significant. In the absence of this affection rales at 
the bases of both lungs are due to congestion. Rales at one apex, with 
failing health, point to the possible onset of tuberculosis. 

Friction Sound. In health the two surfaces of the pleura rub together 
without the creation of sound. If they are inflamed, the surfaces are 
roughened, on account of swelling and dilatation of the capillaries pro- 
ducing a more or less granular surface, or on account of transudation of 
fluid or lymph. Under these circumstances rubbing together of the 
two surfaces creates a sound to which the term friction is applied. It 
is heard at the end of inspiration, and may continue during expiration. 
It is a localized sound, usually at the seat of pain; it is near to the ear 
and is not modified by cough or full breathing, except occasionally by 
the latter when repeated. It occurs in " nests " or " bunches." It may 
be increased by the pressure of the stethoscope. Moreover, it is a fixed 
sound, in that it does not disappear until effusion takes place. It re- 
appears again when the fluid subsides. The above characteristics dis- 
tinguish it from rales. Both, however, may occur together. Although 
almost always of respiratory rhythm, when the pleurisy is in the neigh- 
borhood of the heart the friction may be of cardiac rhythm. Under 
these circumstances it is more distinct during the act of inspiration. It 
is heard as a systolic rubbing along the borders of the heart. 

We not only distinguish the friction sound by the characters just 
indicated, but the presence of pain renders its existence more probable. 
Usually it is heard at the base in the nipple line in front or scapular 
angle behind, and frequently in the axillary region. 

In addition to the friction sound that attends the onset of acute 
inflammation, creaking sounds of the same nature, not unlike the sounds 
produced when an old door is swung on rusty hinges, or when new 
leather is bent, are heard in cases of old pleurisy. Other physical 
signs of pleural adhesions are present, and often a friction fremitus is 
transmitted to the hand. An old friction is often heard at the apex, 
in the neighborhood of old cavities. It attends both inspiration and 
expiration, is not modified by cough, nor has it any of the elements 
of moisture that attend moist rales. The patient may be cognizant 
of the grating or rubbing sensation, and be able to describe this sensa- 
tion during each breath. It may continue a long time after an acute 
pleural effusion has been removed, and is sometimes the source of anxiety 
and inquiry upon the part of the patient. 

Pysemic deposits in the lungs, infarction, bronchiectasis with reactive 
pneumonia, and pleurisy with emphysema, are first revealed by pleu- 
ritic frictions. (Vierordt.) At the base of the right lung they may be 
the first indication, or an early one, of hepatic abscess. (Clark.) The 
pleural friction in the hepatic region must not be confounded with peri- 
toneal friction of respiratory rhythm. In secondary cancer of the liver 
a friction may be heard in the seventh or eighth interspace. 

Metallic Tinkling. The idea imparted to the listener is of the falling 
of some material into fluid in a hollow space. The physical condition is 
that of a cavity partly filled with fluid, partly with air, into which 
there is dropping from an opening above. This is seen in hydro- or pyo- 
pneumothorax and in a few cases of large cavities. The air-chamber 



262 



SPECIAL DIAGNOSIS. 



acts as a consonance-box and resonator, and gives a metallic quality to 
the sound. Other physical signs of cavity and fluid are associated. 
It may be heard when the patient is breathing quietly or only after 
coughing. Sometimes only tinkling is heard, or the sound of a num- 
ber of drops is transmitted. The latter occurs after coughing takes 
place. 

Bell-tympany . The bell sound is heard when air is confined in the 
pleura. If the stethoscope is placed over the pleural cavity, and two 
coins are used as plessor and pleximeter, a distinct metallic or anvil- 
sound is transmitted to the ear. The cavity containing air can be out- 
lined and its extent clearly defined if the metal pleximeter is moved 
about. As soon as it passes over the surface of the chest underneath 
which air is not confined the sound is not heard. Although heard in 
nearly all cases of pneumothorax, there are some cases in which it cannot 
be elicited, probably because of the size of the aperture in the pleura. 

Succussion. The ear is placed to the side of the chest, and the 
patient's body moved suddenly by himself or by the observer. A 
splashing sound is heard. It can only be produced when there is air as 
well as fluid present in a cavity. It was first described by Hippocrates, 
and the term " Hippocratic succussion " has been given to it. It is 
characteristic of hydro-pneumothorax, although not present in all cases 
of this disease. The sound may be audible at a distance. Metallic 
tinkling can usually be secured at the same time. 

Auscultation of the Voice. When the ear or stethoscope is applied to 
the surface of the chest and the patient asked to speak, the vibrations 
of the air in the trachea and bronchial tubes produced by this act are 
transmitted to the chest wall and become audible. It is known as the 
vocal resonance. It is a sign which goes hand-in-hand with vocal or 
tactile fremitus, and is modified by the same conditions which modify 
the latter. In disease it may be increased or diminished. While, in 
general, conditions which increase the fremitus increase the vocal 
resonance also, this is not invariably the case. Sometimes one is in- 
creased and not the other, without there being any evident reason for it. 
It varies in health under similar circumstances. The sound is purring 
or buzzing. It is heard more pronounced at the right apex than at the 
left; in persons with thin chest walls; in individuals in whom the 
voice is low in pitch and strong. It is lessened, therefore, in females 
and children. It is lessened the farther away the ear gets from the 
larynx, and hence is feebler at the bases. It is immaterial which words 
are selected by the patient to create the resonance. It is important for 
the student, however, to become familiar with the resonance of a defi- 
nite series of words which when pronounced do not need any marked 
change in inflection of the voice. The words one, two, three, spoken 
repeatedly, are selected, or ninety-nine used in succession. The tone of 
the patient should not be raised or lowered during the act of speaking. 
Symmetrical portions of the two sides of the chest must be examined 
successively. 

Vocal Resonance Increased. Increased vocal resonance depends upon 
the intensity or extent of the cause. When slightly above normal it 



DISEASES OF THE LUNGS AND PLEURiE. 



263 



is referred to as slight increase, or when the voice is transmitted com- 
paratively distinctly to the ear it is known as bronchophony. This may 
be heard in health over the trachea or the bronchi behind. When heard 
over the vesicular structures of the luug it indicates that the vibrations 
are transmitted by some better conducting material to the eai\ This is 
usually a consolidated lung, and hence : 1. In all cases of consolidation 
the resonance is increased, or bronchophony created ; but in pneumonia, if 
the bronchus is occluded by exudate, it is absent. 2. If the lung is 
collapsed but the bronchi open, the resonance is increased. 3. It is 
also increased in cavities. Sometimes the resonance is intensified and 
the sound even more pronounced than when heard over the trachea. 

Pectoriloquy. The voice may be so distinctly transmitted that we 
have the impression that the patient is speaking into the mouth of the 
stethoscope. If the patient speaks slowly the words may be clearly 
perceived. It is more striking when the patient whispers. The term 
"whispering pectoriloquy " is then applied to it. It is detected over 
a cavity if it communicates with a large bronchus, and in consolidation 
of the lung. 

Vocal Resonance Diminished. Vocal resonance is diminished or 
absent when anything cuts off the supply of air and intercepts the 
vibrations from the part over which the observer is auscultating. Frem- 
itus and resonance are absent over the affected bronchial area which is 
occluded by external pressure, as from an aneurism. Diminution or 
absence of vocal resonance is more marked iu cases of pleural effusion 
(serum, blood, pus, or air) or thickened pleura. The vibrations are 
impeded because of the difference of conducting material. The degree 
of diminution depends upon the amount of effusion. 

Modifications of Vocal Resonance. 1. At the uppermost limit of 
pleural effusions, at which point the layer of fluid is thin, the resonance 
is transmitted in a modified form. It is tremulous and bleating in char- 
acter, and because it resembles the sound of a goat is known as cego- 
phony. It is especially heard at the angle of the scapula, or below it 
in cases of moderate effusion. It is due to the fact that the funda- 
mental tones are intercepted by the fluid while the other tones are 
allowed to pass through and give the peculiar bleating sound. (Gee.) 
2. The vocal resonance may have a metallic character in cases of 
pneumothorax when there is free communication with the bronchus. 

Cavities. Pulmonary cavities are due to destruction of lung by 
abscess, gangrene, or tuberculosis, or to dilatation of the bronchi. 

As there is usually a local increase in the amount of air in cavities, 
there is in consequence a local area of exaggerated resonance, or tympany, 
and with it the occurrence of cavernous breathing, or breathing of an 
amphoric type. The presence of a cavity, however, is often difficult 
to recognize, because of the relation to the surrounding structure or 
because of fluid contents. If the lung about it is the seat of consolida- 
tion the physical signs of this consolidation may override the signs 
of a cavity. If, on the other hand, compensatory emphysema sur- 
rounds the cavity its presence may be scarcely recognized. Moreover, 
the contents of the cavity render the recognition of its presence diffi- 



264 



SPECIAL DIAGNOSIS. 



cult. If it contains a considerable amount of fluid the signs of con- 
solidation alone may be yielded. Much attention has been paid to the 
recognition of cavities, and some methods employed by which it is 
thought they can always be distinguished. While it is a satisfaction to 
determine exactly the presence and location of a cavity, it is not an essen- 
tial to diagnosis. To be able to confirm the presence of an excavation, 
even if the physical signs point to its occurrence, the judgment should 
be controlled by examination of the sputum. If on such examination 
yellow elastic tissue is found, the presence of a cavity is authenticated. 
The methods employed to determine their presence absolutely have been 
named after observers who have devised them. 

First, Wintrictis change of sound. If the cavity communicates with 
a large column of air in the bronchus and percussion is employed with a 
moderate degree of force, the note will change as the patient alternately 
opens and closes the mouth. If the mouth is open wide the sound is 
louder and more distinctly tympanitic and higher in pitch. If the mouth 
is closed the sound is correspondingly lessened and not so tympanitic. 
Indeed sometimes a sound is obtained with scarcely a trace of tympany. 
This change of sound is in all probability due to change in the resonant 
cavities in the upper respiratory tract. It must not be confounded with 
" Williams' tracheal tone," which can be elicited near the junction of the 
clavicle and sternum on the left side in cases of consolidation of the 
underlying portion of the lung, particularly if the force of the blow is 
directed toward the trachea. Strong percussion is necessary to bring 
out Williams' tone. 

Second, interrupted change of sound, also described by Wintrich, is 
distinguished from the simple change, in that it occurs in different posi- 
tions of the body. When the patient is in an upright position it may 
be present ; while, if in the recumbent position, it cannot be detected, 
or the converse may be true. The change in position changes the rela- 
tion of the bronchus to the cavity, on account of which the varying 
tympanitic sound is produced. 

Third, Gerhard? s change of sound. This change depends upon the 
alteration of the level of the fluid when the patient assumes the upright 
or dorsal position. It is not necessary that the cavity communicate with 
the large bronchus. It is a certain symptom of a cavity, but is rare. 
The sound changes in pitch and in the degree of tympany. It may be 
absolutely dull over the lower part of the cavity when the upright posi- 
tion is assumed, because the fluids gravitate to this portion and come in 
contact with the chest wall. 

Fourth, Friedreich's respiratory change of sound. The pitch of the 
sound becomes higher at the end of a deep inspiration. It depends 
upon increased tension of the chest wall and lung tissue as well as the 
wall of the cavity during the act of inspiration. It may be the cause 
of confusion, which is obviated by percussing at the same stage of the 
breathing each time, or percussing only on superficial breathing. 

Fifth, Seitz has called attention to a form of breathing named meta- 
morphosing. Inspiration begins harshly bronchial, then becomes faintly 
bronchial, the latter sound being heard also in expiration. It is said to 
be a sure sign of cavity. 



DISEASES OF THE LUNGS AND PLEURJ. 



265 



Mensuration. By mensuration the results secured by palpation are 
confirmed and more accurately attained. The size of the chest is 
secured and its degree of expansion ascertained. If the method is 
resorted to from day to day it can be graphically recorded by tracing 
sections on paper, and delicate changes therefore definitely ascertained. 
The circumference of the chest is measured by means of the ordinary 
tape measure or by metal tapes joined together by a hinge. The latter 
can be made to fit accurately the circumference of the chest, and are 
essential in order to transfer the section to paper. The middle of the 
hinge is held firmly over the spinous process of the vertebra, while the 
two limbs are carried around the chest, moulded to all inequalities, and 
crossed in front, one above the other ; a mark is made on each where it 
crosses the middle line. The measurement should be taken at about 
the level of the nipple, and care should be taken to have the level 
uniform in front and behind. The outline secured by this method 
need not be disturbed, as by flexion on the hinges we are enabled to 
remove it intact. The tapes are carefully transferred to a sheet of 
paper on which imaginary diameters have been marked. After fixing 
the corresponding points of the tapes on the lines of the respective 
diameters, the outline can then be traced. 

Woillez's cyrtometer is a chain with links which is used to ascertain 
the exact circumference. The diameter of the thorax is secured by 
means of caliper compasses. The antero-posterior diameter should be 
taken on a level with the nipple and at the insertion of the second rib 
behind; the transverse diameter at the highest points of the axillae. 
The length of the chest may be ascertained by measuring in the mid- 
clavicular line from the clavicle to the border of the ribs. It is impor- 
tant to remember that the right side of the chest measures a little more 
than the left in people who are right-handed. 

The respiratory capacity is estimated by measurement of the circum- 
ference of the chest. This is secured by taking the measurement at the 
end of complete expiration and then at the end of complete inspiration. 
In health the difference between the two should be from five to ten 
centimetres (two to four inches). If the expansion is less than two inches 
it is considered deficient by insurance companies, and the risk is 
not regarded as first-class. The expansion is less in women. In taking 
the measurement the observer must be particular to keep the terminal 
portion of a tape measure fixed in the median line of the structure. The 
other portion is to be held in the hand, so as to move with inspiration 
and expiration. Always mark in advance the anterior mesial line and 
note the exact level at which measurements are made when they are 
taken daily. 

Spirometry. By means of the spirometer Mr. John Hutchinson has 
been able to estimate the quantity of air taken in with each inspiration 
and discharged with expiration. By it the respiratory or vital capacity 
is estimated. The data ascertained are not of much diagnostic signifi- 
cance, although if measurements are made from day to day we may be 
able to estimate the extent of recovery from disease of the lung which 
was incapacitated. We can also estimate the degree of interference with 
breathing by disease below the diaphragm. By means of Walden- 



266 



SPECIAL DIAGNOSIS. 



burg's pneumotometer the respiratory pressure of air on inspiration and 
expiration is determined. Expiratory pressure is diminished in emphy- 
sema, and the degree of diminution may furnish a clue to the severity 
of the disease or the degree of improvement. It is to be remembered 
that it is always greater than expiratory pressure in health. It is 
natural to find that inspiratory pressure is lessened in stenosis of the air- 
passages in phthisis and in pleural effusions, although it is not of diag- 
nostic significance. 

Combination of Physical Signs. In order to determine the 
physical condition of the lung it is neeessary to draw conclusions from 
the results derived by all the methods of physical examination. It is 
the exception that any one sign is pathognomonic of a physical condi- 
tion. If the student will glance over the abnormal physical conditions 
which may take place in the lung he will find that they may be divided, 
first, into physical changes in the lung proper, and, second, into physical 
changes in the pleura. With regard to the lung, it will be further 
noted that the changes are due to an increased amount of air or to a 
diminution of the amount of air. 

Increased amount of air may be general, unilateral, or local, and be 
indicated by a combination of physical signs which are usually unerring. 
On inspection (a) enlargement, general, unilateral, or local ; (h) increased 
action in general emphysema, although with diminished respiratory 
excursion; when unilateral or local, increased action and increased 
expansion (compensatory emphysema). On palpation, inspection con- 
firmed, and vocal fremitus diminished when the increased amount of air 
is general, slightly increased when it is unilateral or local. On percus- 
sion, in each instance exaggerated resonance or tympany. On ausculta- 
tion, when general (emphysema), feeble respiratory murmur, with 
prolonged expiration ; when unilateral or local, exaggerated respiratory 
murmur. The difference in the physical signs of increased amount of 
air are not due to the difference in quantity, but to the associate physical 
condition and the force of the movement of the air. The diminished 
expansion and feeble respiratory murmur in emphysema are due to the 
inability to exhale the air because of the diminished elasticity of the 
lung, while the occluded bronchioles from bronchitis lessen the fremitus. 
In cavities — local increase of air — the physical condition of the tissue 
which surrounds them modifies the physical signs. 

Decrease in the Amount of Air. The diminution in the amount of 
air from change in the physical condition of the lung is due to consoli- 
dation or to collapse of the lung. The latter occurs when the bronchus 
is obstructed, the former in congestion, pneumonia, gangrene, abscess, 
forms of tuberculosis and hemorrhagic infarct. The physical signs are 
the same under all circumstances, except in collapse: expansion less- 
ened, fremitus increased, dnlness, bronchial breathing. The signs vary 
with the degree of consolidation as follows : Slight increase to greatly 
increased fremitus, impaired resonance to complete dulness, broncho- 
vesicular to bronchial breathing. In tuberculosis there may be flatten- 
ing of chest wall, but otherwise the signs are the same. The presence of 
new sounds depends upon the amount of secretion or fluid, as is the case 
when there is increase of air in the part. 



DISEASES OF THE LUNGS AND PLEURJ!. 



267 



Broadly speaking, therefore, in affections of the lung proper, the 
two conditions just mentioned must be differentiated — air increased, air 
diminished. We do not refer to bronchitis, because no physical change 
takes place in the lung, and the signs depend upon the amount of fluid 
in the tubes. 

The Pleura. If satisfied that the physical condition is not due to 
change in the lung structure, the state of the pleura must be investigated. 
Here, too, the physical condition may be due to an excessive accumula- 
tion of air or to an accumulation of solid material. In effusion there is 
enlargement of the affected side, there is diminished movement, and also 
diminution of fremitus and of resonance. When air is present, how- 
ever, there is tympany ; when fluid, there is dulness on percussion. 

The problem may be looked at from another side, however. 1. The 
percussion note at once indicates that there is an increased amount of 
air. Is this in the pleura or the lung? If in the pleura it can only be 
unilateral, and is recognized by the diminution of movement and of 
fremitus, as against increased movement and fremitus when due to uni- 
lateral increase of air in the lung proper (compensatory emphysema). 
2. The percussion note, on the other hand, shows dulness or the 
absence of air. Is this in the pleura or in the lung? A distinction 
between consolidation and pleural effusion must be made. In con- 
solidation there is increased fremitus, increased vocal resonance, bron- 
chial breathing, and dulness on percussion. (See Fig. 44.) There may 
or may not be contraction. In pleurisy with effusion, absent move- 
ment, absent fremitus and resonance, dulness on percussion, feeble, 
distant, or absent breath-sounds. (See Fig. 45.) The distinction of 
the two physical conditions seems easy, and yet the physical signs 
may not be sufficiently definite to warrant a positive conclusion. There 
are cases in practice in which it is almost impossible to determine 
which of the two conditions is present. It has been stated previously 
that bronchial breathing may be present in pleural effusions. On the 
other hand, in certain cases of consolidation it may be absent and the 
vocal fremitus and resonance also absent. Apart from reliance on the 
associate general and local symptoms, we must look to two methods 
for corroborative proof of the presence of either condition. First, 
exploratory puncture; and, second, the involvement of organs, or 
change of the anatomical relations of parts. The former has been 
spoken of The latter includes displacement of the heart to the right 
or the left, depending upon the seat of the effusion ; dislocation of the 
liver, and, in cases of left pleural effusion, obliteration of the half-moon 
space (Traube's line). 

Sputum. By this term is generally understood all the products of 
secretion of the mucous membrane of the respiratory tract, and other 
substances that may be brought up through the respiratory tract. The 
characters of sputa in disease vary with the part affected as well as 
with the pathological nature of the disease. It is always well to 
examine each specimen both macroscopically and microscopically. 

Method of Collection. Sputum that is to be examined should be col- 
lected in perfectly clean vessels, containing no fluid, preferably in glass 



268 



SPECIAL DIAGNOSIS. 



or white earthenware spittoons, and care should be exercised against 
the entrance of extraneous substances, as tobacco or particles of food 
from the mouth, or from outside sources, or from the stomach through 
vomiting. Tobacco, prunes, and bread-crusts are at times mistaken for 
blood. It is also necessary to see that the matter sent for examina- 
tion is derived from the lungs, and is not simply the oral and faucial 
accumulations. If practicable, the mouth and pharynx should be first 
rinsed with a warm alkaline solution. The true sputum is coughed up. 

We usually require, in the examination, one or two glass dishes or 
plates, a large and a small piece of window glass, mounted needles, and 
forceps ; and for microscopic work, in addition to these, a good micro- 
scope and accessories, and certain staining fluids. 

In describing sputum we note the quantity in twenty-four hours, its 
color, odor, specific gravity, its composition and consistency, whether 
mucous, purulent, muco-purulent, frothy, watery, bloody, tenacious 
or viscid, and whether it is made up of separate layers or is homo- 
geneous. 

The quantity m twenty-four hours varies from a few c.c. to even 1000 
c.c, as in a discharging empyema. 

The color changes with the composition and the nature of the dis- 
ease ; thus in acute bronchitis and oedema of the lung it is white ; 
in purulent sputa, no matter what the cause, it is yellow or greenish 
yellow; in pneumonia " rusty"; in abscess of the liver with amoeba 
characteristics, brownish- red or like " anchovy sauce." 

The odor is by no means characteristic in most cases. That of bron- 
chiectasis, gangrene, and putrid bronchitis is particularly heavy and 
foetid, a characteristic which renders its origin almost unmistakable. 

The reaction is always alkaline. 

The specific gravity may vary from 1.0043 (mucous sputum) to 
1.0375 (serous). (Von Jaksch.) 

Varieties of Sputum. Mucous Sputum,, on account of the mucin, 
is usually glairy, clear, and tough. It is seen in acute brouchitis in the 
early stage and oedema of the lung. There is in health a small amount 
of mucus expectorated, which in cities and smoky towns is apt to contain 
black pigment particles, due to inhaled soot. 

Purulent Sputum is composed almost entirely of pus. Typical puru- 
lent sputum is that from an empyema discharging through a bronchus. 
It may also occur in bronchiectasis, chronic bronchitis, abscess of the 
lung, of the liver, or more rarely of the mediastinum, discharging 
through a bronchus; or it may be the discharge of a tubercular vomica. 
The special condition can usually be determined by microscopical 
examination and the accompanying symptoms and signs. 

Muco-purulent Sputum. It is most common to have mucus and pus 
mixed together in varying proportions, and then it is termed muco- 
purulent. Such sputa may be found in the same conditions as purulent 
sputa. When flat, coin-shaped masses are formed, sinking to the bottom 
if the vessel contains water, as in phthisis and chronic bronchitis, it is 
known as " nummular " sputum ; or it may be more spherical, and is 
then called globular. At times the sputa may be seen to separate into 
three distinct layers, the upper frothy, muco-purulent, greenish-yellow 



DISEASES OF THE LUNGS AND PLEURA. 269 



or dirty green, sometimes lumpy, sometimes composed of shreds ; the 
middle thin and watery, with shreds from the upper layer; and the 
bottom layer, apparently made up of pus and debris, opaque and 
without air-bubbles. It points to gangrene of the lung in most in- 
stances, but may also occur in bronchiectases. 

Watery or serous sputum is the result of oedema of the lung. 

Bloody Sputum — Hcemoptysis. As blood in sputum is always of im- 
portance, the entrance of substances as mentioned above, which simulate 
it in appearance should be guarded against. It may be seen in greatly 
varying quantities and have many different sources, and have slight or 
grave significance. It may come from the gums, nose, pharynx or 
larynx, and in all cases such sources should be examined. Again, there 
may be cases where bleeding from the stomach (haematemesis) simulates 
hemorrhage from the lungs, and still more often people speak of vomit- 
ing blood that really has come from the lungs. Usually that from the 
lungs is much more frothy and bright red, while that from the stomach 
is darker and acid, and may contain particles of food. Diagnosis is 
more difficult when some blood from the lungs is first swallowed, then 
vomited. Usually there is a distinct history of preceding cough, and 
for some time afterward small amounts of blood continue to be expec- 
torated. (See Lungs : hemorrhage.) 

Small amounts of blood streaking the mucous sputum or appearing 
in small clots often come from the throat or nose or upper air- passages, 
but may come from the lungs. Muco-purulent sputum streaked with 
blood frequently is indicative of phthisis. In pneumonia the rusty 
sputa are the result of an admixture of mucus and blood, and usually 
contain small air-bubbles. When the blood-coloring matter is changed 
there may be a yellowish or greenish tinge. In certain cases of chronic 
pneumonia, where the blood remains longer in the lung tissue, the 
expectoration has a darker color. Where there is slight leakage from 
an aneurism the same may be found. Pneumonia accompanied by 
expectoration of large amounts of blood is often indicative of a tuber- 
culous origin. Blood may be mixed with the greenish expectoration of 
gangrene. According to Finlayson this is especially true in children. 
In chronic valvular disease of the heart, frothy mucus containing more 
or less blood is commonly seen, and likewise in oozing from aneurism. 
" Currant jelly " sputa are more or less characteristic of malignant growths 
of the lungs, while the expectoration from a liver abscess with 
amoebae is reddish-brown in color, from the mixture of blood, pus, and 
bile elements, and is not unlike "anchovy sauce. 77 We may have hemor- 
rhage from the lungs as a part of a general hemorrhagic tendency, as 
in purpura and hemorrhagic smallpox ; and in so-called " vicarious men- 
struation " there may be haemoptysis. But a patient presenting such 
symptoms should be examined with the greatest care to exclude actual 
pulmonary complication. When great quantities of blood are expecto- 
rated we suspect tuberculosis of the lung, aneurism, or cardiac valvular 
disease. 

The unaided eye may distinguish other foreign substances, such as 
fibrinous casts of the bronchi or trachea and spirals ; but full considera- 
tion of them will be given farther on. 



270 



SPECIAL DIAGNOSIS. 



Microscopic Examination of the Sputum. White blood-cor- 
puscles are present in all sputa, but in varying numbers and size. They 
are most abundant in purulent sputa. Often they contain fat drops 
and pigment particles. 

Red blood- corpuscles are to be found in the majority of sputa. They 
may be so few as not to give a red color. The source is often high up 
in the respiratory tract. When in considerable number the sputum is 
more or less tinged, and in haemoptysis it is almost wholly made up of 
red cells. Usually each cell is well preserved, but they may be recog- 
nized as pale bodies or as rings, the pigment remaining in the sputum 
as pigment particles or as crystals of hsematoidin, as in pneumonia. 

Epithelium. Two general varieties are found in the sputum — 
squamous and cylindrical. The former comes from the mucous mem- 
brane of the mouth, the tongue, tonsils, true vocal cords, and perhaps 
from the salivary and small bronchial glands. It has no clinical 
importance. 



Fig. 52. 




Epithelium, leucocytes and crystals of the sputum. (Eyepiece III., obj. 8, A. Reichert.) 

a, a\ a!', Alveolar epithelium, b, Myelin forms, c, Ciliated epithelium, d, Crystals of calcium 
carbonate, e, Hsematoidin crystals and masses. f,f,f", White blood-corpuscles, g, Eed blood- 
corpuscles, h, Squamous epithelium. (Von Jaksch.) 

Cylindrical cells in sputum are rarely perfect. It is uncommon to 
find the cilia intact, and still more so in motion, while the body of the 
cells is likely to be changed. They are found in inflammations of the 
trachea and bronchi, or the posterior nasal fossa — a locality where, it 
must be remembered, ciliated epithelium exists. 

"Alveolar" epithelium, so called, when found in the sputum, is 
more important than the above, as different observers consider its 
presence to have more or less clinical significance. The cells are 
elliptic or round, somewhat larger than white corpuscles, with a 
single nucleus, which is indistinct without the addition of acetic acid. 
The protoplasm is granular, and contains within it particles of iron- 
dust, carbon, or blood-coloring matter, and often fat drops. They may 
also have undergone complete fatty degeneration, and they have been 
considered the source of myelin drops in the sputum. 

It is to be found in the sputum of chronic bronchitis, acute and 
chronic pneumonia, and tuberculosis of the lung. 



DISEASES OF THE LUNGS AND PLEURJI. 



271 



Detection. A small bit of sputum is placed on a microscopic slide 
and a cover-slip applied. Examine with varying powers, and again 
after acetic acid is added stain the cells with an aqueous solution of 
methylene-blue. 

Elastic fibres. As the presence of elastic fibres in sputa is of 
much import, denoting destruction of the lung tissue, bronchi, or 
the larynx or bloodvessels, their presence from food remaining in the 
mouth must be especially guarded against. They may be mistaken for 
fat crystals. They are found as single threads in bundles, or showing an 
alveolar arrangement. They are to be recognized by the double con- 
tour and curling ends, and at times by the alveolar arrangement. They 
may be due to tuberculosis, abscess of the lung, bronchiectasis, gangrene 
of the lung, pneumonia (Von Jaksch) and rarely to destructive diseases of 
t he larynx. In a very great majority of cases they are due to tuberculosis. 
It is uncommon to find them in gangrene, probably because, as Traube 
first suggested, they are destroyed by a ferment. 



Fig. 53. 




Elastic fibres of lung tissue obtained from sputa after digestion in caustic soda. 
(Drawn by Dr. John Wilson.) 



Elastic tissue from the alveoli often shows the diagnostic alveolar 
arrangement ; the fibres that form a bronchus are branched ; those from 
an eroded artery appear in the form of a network, or the fibres are 
bound together. 

Detection. The method employed by Osier, modified from Sir An- 
drew Clark's, is the best. A small amount of the thick, purulent 
portions of sputum is pressed out into a thin layer between two 
pieces of plain window-glass, 15x15 cm. and 10x10 cm. The par- 
ticles of elastic tissue appear on a black background as grayish-yellow 
spots, and can be examined in situ under a low power. Or the upper 
piece of glass is slid off till the piece of tissue is uncovered, when it is 
picked out and examined on a microscopic slide, first with a low power, 
as the one or one-half inch objective, and then with a higher power. 
At first there will be some difficulty in distinguishing with the naked 
eye between elastic fibres and particles of bread or milk globules, or 
collections of epithelium and debris, but with practice such mistakes 
are rarely made, and the microscope always reveals the difference. This 
method is much easier of accomplishment and quite as satisfactory in 



272 



SPECIAL DIAGNOSIS. 



results as the one generally employed — boiling an equal quantity of 
sputum and solution of caustic potash (8 to 10 per cent.) for a short 
time, and allowing it to staud for twenty-four hours in a conical glass. 
The elastic tissue remains intact and is found in the sediment. 

Connective tissue and cartilage, in fragmentary bits, are rare constitu- 
ents of sputum. The former may occur with abscess or gangrene of 
the lung, and the latter when there is ulceration of the larynx. 

Fibrinous Coagula. These striking tree-like bodies are found in the 
sputa of plastic bronchitis, and at times in that of pneumonia, phthisis, 
and in diphtheria and croup where there has been an extension into the 
bronchi. They are usually mixed with mucus and are rolled up into a 
mass. Their peculiar form is best seen when they are washed and 
unravelled in water. They are then seen to be a complete mould 
of a small bronchus with its ramifications. The size varies greatly. 
They may be many centimetres long. In fibrinous bronchitis the size and 
shape of the moulds in different attacks may be exactly similar, as if 
they came from the same bronchus. They are grayish-white in color, 
hollow, and on transverse section are seen to be made up of cast upon 
cast. Leucocytes, blood cells, and alveolar epithelium are found in the 
meshes by the microscope, and at times Charcot-Leyden crystals and 
Curschmann's spirals also. They are almost pathognomonic of fibrin- 
ous bronchitis. When they occur in any number in pneumonia they 
make the prognosis unfavorable. Blood-casts of the smaller bronchi 
have been found in cases of haemoptysis. They are rare, and have no 
apparent connection w r ith the fibrous coagula. 

Spirals. Under this name are included spiral bodies that are found 
in the sputa of bronchial asthma, aud occasionally in that of pneumo- 
nia and capillary bronchitis (V. Jaksch), and chronic pulmonary tuber- 
culosis (Vierordt). At the beginning of an asthmatic attack, tough 
rounded balls are expectorated — " perles" of Laennec, which, if freed 
of the mucus surrounding them and spread out on glass with a dark back- 
ground, may be seen by the naked eye to have a twisted spiral form. 
With the aid of the microscope they are found to be made up of spirally 
arranged mucin in a more or less tight twist, with many cells from the 
alveoli and bronchi. In some of these spirals a shining central thread 
runs through the entire length of the spiral like a core, remarkable for 
its clearness and its high refractive index. The fine fibres composing 
the spiral may be closely arranged or not. Epithelium and Charcot- 
Leyden crystals may be found lying among the coils. The main con- 
stituent of the spirals is mucin, and Osier has suggested that the central 
thread is made up of transformed mucin. On the other hand Von 
Jaksch believes it to be chemically distinct from the mucin spiral. 
Vierordt considers it either made of tightly twisted central fibres or 
to be an optical image of a core cavity. They are probably the result 
of an acute bronchiolitis. Why they should assume this remarkable 
form is still au open question. It has been suggested (Osier) that the 
ciliated epithelium of the bronchi may have a rotatory action, and their 
action combined with the spasm of the bronchioles tends to the spiral 
formation. 

That there is a connection between the spirals and Charcot-Leyden 



DISEASES OF THE LUNGS AND PLEURA. 



273 



crystals seems very probable, as the latter are absent from the sputum 
at the beginning of an attack of bronchial asthma, but if a portion of 
such sputum is allowed to stand for twenty- four to forty-eight hours, so 
that evaporation does not take place, crystals will be found. As has 
been said, the crystals are often found among the spirals, and this when 



Fig. 54. 




Spirals from bronchial tubes. X 80. (After Leyden.) 



they are seen nowhere else. Later on the spirals disappear, but crystals 
derived from them (?) continue to be expectorated. (See Fig. 54.) 

The method of examining for spirals is as given above. 

Crystals. Charcot-Leyden, cholesterin, hsematoidin, fatty, tyrosin, 
oxalate of lime and triple phosphate crystals are to be fouud in sputa 
under various conditions. 



18 



274 



SPECIAL DIAGNOSIS. 



Charcot-Leyden crystals are octahedral, sharply pointed, colorless, or 
slightly bluish, soluble in warm water, alkalies, and acetic and mineral 
acids. The practised unaided eye may recognize these as small 
yellowish bodies, not unlike grains of sand ; under the microscope they 
are unmistakable. Their size varies greatly. They occur most abund- 
antly daring (invariably) and after an attack of bronchial asthma ; they 
have also been seen in the sputa of acute and chronic bronchitis and 
tuberculosis. They are identical with crystals found in semen, faeces, 
and in leuksemic blood and bone-marrow. Their connection with spirals 
has been mentioned above. Schreiner considers them to be the phos- 
phate of an unknown base, which Ladenburg and Abel think may be 
identical with ethyl eninim. (Von Jaksch.) 

Detection. Examine the sputum of an asthmatic patient a day or two 
after the beginning of an attack for round, hard, yellowish bodies, 
and place these under the microscope with different powers. They are 
readily recognized. 

Fig. 55. 




Charcot's crystals. (Scheube.) 



Cholesterin crystals. These crystals are similar to those of choles- 
terin found elsewhere, being thin rhombic plates, often with irregular 
corners and high refractive index. They are soluble in ether ; and 
when treated with dilute sulphuric acid and tincture of iodine they 
become violet, blue, or green, and then red. They may be present in 
the sputum of tuberculosis, abscess and hydatid abscess of the lung, 
and in pus from an abscess of another organ, as the liver. They have 
but little clinical significance. 

Hcematoidin crystals. Hsematoidin crystals are at times recognizable 
by the naked eye as distinct spots of yellowish or brownish red color. 
Under the microscope they have a brownish yellow or ruby-red color, 
and are either in the form of small rhomboid prisms or of fine needles, 
single or arranged in bunches of various shapes, or as free pigment 
particles without crystalline form ; smaller particles may be contained 
within a leucocyte. Their presence indicates that blood has remained 
in the respiratory tract for some time before being expectorated, or that 
an abscess has discharged into a bronchus. They occur in phthisis, following 
hemorrhage; in thoracic aneurism when blood is oozing into the lung ; in 
gangrene; in abscesses discharging through a bronchus. Von Jaksch 



DISEASES OF THE LUNGS AND PLEURJ. 



275 



states that when the crystals are contained in cells there has been a preced- 
ing hemorrhage, but that when there is considerable free hsematoidin one 
infers that an abscess of a neighboring organ has discharged into the lung. 

Fatty crystals. Crystals of margaric acid occur as long, thin needles, 
gently curved or bent at one end much like a fish-hook, and either 
singly or in bundles. They are found iu unhealthy pus — as in gan- 
grene, putrid bronchitis, brouchiectasis, and tuberculosis ; in the plugs 
formed in inflamed tonsils ; and in purulent sputum in general which 
is allowed to stand in a warm place. They dissolve in ether and boil- 
ing alcohol ; and this characteristic, together with the regularity of their 
curve, should distinguish them from elastic fibres, with which they are 
sometimes confused by beginners. 

Tyrosin crystals have been found in the sputum of putrid bronchitis 
and empyema discharging into the lung, and usually in conjunction with 
leucin. They are most abundant in sputa allowed to stand for some 
time. Under the microscope they appear as fine needles, and can be 
mistaken for fatty crystals. They are without diagnostic importance. 

Oxalate of Lime and Triple Phosphates have been noted occasionally in 
sputa ; the former in a case of diabetes and also in an asthmatic ; the 
latter occur only in alkaline sputa, as they are soluble in acids. 

Corpora, Amylacea. Starch-like bodies have been found in the 
sputum after pulmonary hemorrhage has taken place, and in that of 
pulmonary gangrene. They have the shape of starch corpuscles, and 
sometimes give the amyloid reaction with iodine or iodide of potassium. 
They are at present without clinical significance. 

Parasites. A. Animal Parasites. Echinococcus cysts are to be 
found in sputum, generally broken into fragments, and only very rarely 
in a perfect whole, when there is rupture of a cyst of the liver or lung 
into a bronchus. Scolices and free hooklets from the same may be recog- 
nized, and pieces of the cyst wall will be known by their remarkable 
formation. Their presence is of great clinical value. 

Infusoria have been found in the expectoration from gangrene of the 
lungs. They belong to the monad and cercomonad varieties. 

Distoma haematobium eggs may occur in sputa when the lung tissue 
is broken down by its presence, the eggs being thrown off in the sputum. 

Amoeba Dysente?ice (Amoeba Coli). Of far more interest and impor- 
tance is the presence of this parasite in the expectoration. A full de- 
scription of the amoeba will be given in the chapter on the Faeces. They 
are the same in every respect when found in the sputum, except that 
they are often slightly larger. The sputum containing the amoeba is 
partly diffluent, tenacious, frothy, bright red in color at first, due to the 
presence of blood, and later brick or brownish red, sometimes bile- 
stained. Small yellowish white cheese-like particles are seen. Upon 
exposure to the air the sputum becomes thin, syrupy, and oily, and it 
then looks much like anchovy sauce. The sputa are alkaline, and of a 
faintly sweetish odor, never putrid. Later on they become more puru- 
lent, somewhat nummular, reddish yellow, and contain less blood. If 
there is a favorable termination they become more fluid and frothy, 
with less blood and pus, and on standing show the three layers. The 



276 



SPECIAL DIAGNOSIS. 



quantity varies from 25 c.c. to 500 c.c. in twenty-four hours. Under 
the microscope will be found, besides the amoeba, red blood-corpuscles, 
leucocytes, alveolar and oval epithelium, and bodies looking like degen- 
erated liver cells without a nucleus ; and occasionally elastic fibres, 
hsematoidin, leucin, ty rosin, and Charcot- Ley den crystals and bacteria are 
seen. The cheesy particles are made up of amorphous granular matter 
and oil globules. Amoebse are constantly present in varying numbers, 
usually not so many as in the stool, but somewhat larger. The number 
varies from day to day, and diminishes with the disappearance of the 
cough and expectoration. The sputa should be examined as soon after 
their discharge as possible, and in the interim should be kept at a tem- 
perature of 30° to 35° C. If examined on a warm stage active move- 
ments of the amoebae will be kept up much longer. 

They should be examined under various powers : J, -jL or ^, and 
inch objectives. Of these the \ or \ inch will be found most suitable 
for following the movements. They measure from 10/^ to 20/^. They 
will be readily recognized by their size, formation and movements. 
(See Faeces for further description.) That they have important clinical 
value is true, as cases have been reported in which the observer diag- 
nosticated hepatic or hepato-pulrnonary abscess secondary to amoebic 
dysentery, by the peculiar anchovy-sauce expectoration and subsequent 
detection of the amoebae. 

B. Vegetable Parasites. Fungi — Non- Pathogenic : Moulds. 
Gidium albicans may be a constituent of the sputum when the bronchi are 
invaded by it, but usually it is from the saliva. Certain other moulds 
have lately been considered to cause disease of the luugs by multiplica- 
tion, but nothing very definite has resulted from the experiments thus 
far made. 

Yeast fungi. Yon Jaksch reports having seen scattered yeast-cells 
in the pus from a phthisical cavity. Otherwise we have no knowledge 
of yeast being found in sputa. 

Fission Fungi. Leptothrix. Leptothrix occurs alone in the sputum 
or in the bronchial plugs in putrid bronchitis, along with fatty acid and 
haematoidin crystals. It is probably derived from the mouth, having 
thence entered the air-passages, or it is taken up from the mouth 
by the expectoration. It is recognized by its staining blue with iodine 
and potassium iodide. 

Sarcinm pulmonalis. Sarcinae may be seen in sputa. They are 
larger than sarcinae ventriculi, with which they have no connection, 
nor have they pathological significance when present in sputa. 

Non -pathogenic bacilli and cocci may occur in all sputa, but are 
without significance. They are more numerous in foetid sputa. They 
stain with methylene-blue and other simple dyes. 

Pathogenic Fungi. Tubercle Bacillus. The organism which is the 
cause of tuberculosis is a rod, straight or slightly curved, without 
motion, varying in length from 2^ to 5" (about J to J the diameter of 
a red corpuscle). It usually has a beaded appearance when stained, 
due to the spores present, which do not take up the stain that affects 
the rod as a whole, and which often slightly bulge beyond the edge. 
The bacillus of tuberculosis cannot be recognized in the sputum unless 



DISEASES OF THE LUNGS AND PLEURA. 



277 



stained, and in the staining it shows a peculiarity which belongs to only 
one other organism — the bacillus of leprosy. As under ordinary con- 
ditions this latter bacillus is not met with, this peculiarity in staiuing 
is diagnostic of tubercle bacilli. 

Preparation of Sputum and Method of Staining Tubercle Bacilli. A 
small amount of the purulent portion of the sputum is spread in a thin 
and uniform layer on a perfectly clear cover-glass by means of forceps, 
needles, or the " Oese," 1 which must previously be held a moment in the 
flame of a Bunsen burner or spirit lamp; or by pressing a small amount 
of sputum between two cover-glasses, then sliding them apart. It is then 
dried in the air, or more quickly by holding the cover-glass with forceps 
some distance above the flame of a burner or lamp. Finally, it is to be 
passed three or four times through the flame, and so " fixed." The edge 
of the cover-glass, with sputum side up, is then grasped with forceps and 
covered with the staining solution, care being taken to prevent the fluid 
from extending to the under surface, and held in or just above the flame, 
until the solution boils for a second or two or a bubble rises. When the 
excess of the solution is washed off in water, the slip is treated with the 
decolorizing agent until the color is almost or wholly removed. It is 
again washed in water to remove the excess of the decolorizer, and 
mounted for examination, or given a contrast stain ; the latter is prefer- 
able. If fuchsin has been used to stain the tubercle bacilli, methylene- 
blue is a good contrast stain; while if gentian- violet was selected, 
Bismarck-brown is better in contrast. These contrast stains are made 
as needed by dissolving enough of the dye in a few c.c. of water to 
make the solution as seen through a test-tube of 14 cm. diameter only 
transparent, and then filtering ; or a concentrated watery solution may be 
made for stock just as the concentrated alcoholic solution of fuchsin and 
gentian-violet were made, diluting a small quantity of this when needed 
with enough distilled water to make it just transparent in a similar test- 
tube. To apply the contrast stain, place a few drops of the same on the 
cover- glass that has been prepared as above — stained, decolorized and 
washed — allow it to remain for thirty or forty seconds, wash off in 
w T ater, and mount for examination on a glass slip, in water, oil of cloves, 
or Canada balsam. A drop of water will serve perfectly well for ex- 
amining when the preparation is not to be preserved. In the microscopic 
examination use a y 1 ^- inch oil-immersion lens and Abbe condenser, or, 
at the least, a T or -J- inch objective. If gentian-violet has been used 
the tubercle bacilli appear as dark blue rods, with all other bodies 
brown, if Bismarck-brown is used for contrast stain ; while with fuch- 
sin staining for the tubercle bacilli, and methylene -blue as a contrast, 
the former will be found as red rods in a blue field (background). 
(See Plate L, Fig. 1,a.) 

The above rapid method of staining takes much less time than the 
method usually described, and gives most satisfactory results. The steps 
in the old method are the same as given above, except that instead of 
placing the staining solution on the smeared and dried cover-glass, and 

1 This most useful instrument is made by fusing a piece of glass rod 10 to 15 cm. long and 
inserting into the fused end a piece of platinum wire about 5 cm. long. The free end of the wire 
remains straight, or, better still, is bent into a loop. 



278 



SPECIAL DIAGNOSIS. 



holding it in or above the flame until the solution boils, the cover-glass is 
floated in a cold solution in a watch-glass, sputum side down, for twenty- 
four hours, or in a hot solution for six to eight minutes, or until moisture 
appears on the upper surface of the cover-glass. The remaining steps 
are similar. 

Tubercle bacilli do not stain with the simpler dyes, but when 
stained by solutions of dyes made more penetrating by the addition of 
aniline oil, carbolic acid, or like substances, they retain the color when 
subjected to decolorizing agents. In this they differ from all other 
organisms, except, as stated, the bacillus of leprosy. 

A number of methods have been devised for the detection of this 
bacillus by means of its peculiar action toward stains. The most satis- 
factory are those known as the Koch-Ehrlich, Ziehl-Neelsen, Gabbett, 
and Gibbes. These methods differ chiefly in the solutions used. Slightly 
modified from the original in execution, they are as follows: 

A. Koch-Ehrlich method. 

Solutions Used. 

I. Concentrated alcoholic solution of fuchsin or gentian- violet. 
II. Saturated solution of aniline oil in water. 

Ill Thirty per cent, solution of nitric acid in water (decolorizing solution). 

I. Place in a clear bottle fuchsin or gentian-violet in substance to 
one-fourth its capacity, and fill with alcohol (95 per cent.) ; shake well 
and cork and allow to stand for twenty-four hours. If all of the dye 
has been dissolved add more and shake, and stand for another twenty- 
four hours, and so on until some of the dye remains permanently un- 
dissolved at the bottom of the bottle. This solution remains good until 
used. 

II. To about 100 c.c. of distilled water in a flask or other suitable 
vessel, add aniline oil, drop by drop, shaking the flask continuously, 
until the solution is opaque, or drops of the oil float on the surface, 
then filter through moist filter paper until the filtrate is perfectly clear. 
This solution must be made fresh as needed. 

III. Mix a few c.c. of nitric acid and water in about the above pro- 
portion, never stronger, each time bacilli are to be stained. 

The Koch-Ehrlich solution is made by adding 11 c.c. of the fuchsin 
or gentian solution (No. I.), and 10 c.c. of absolute alcohol to 100 c.c. 
of the clear aniline filtrate (No. II.). It should not be used after it is 
a week old. 

B. Ziehl-Neelsen method. 

Solutions Used. 
I. Carbolic-fuchsin solution : 

Distilled water 100 c.c. 

Carbolic acid (crystalline) 5 grammes. 

Alcohol 10 c.c. 

Fuchsin in substance 1 gramme. 

This solution can also be prepared by adding saturated alcoholic 
solution of fuchsin (see above) to a 5 per cent, watery solution of car- 
bolic acid until a metallic lustre is seen on the surface of the fluid. 
This solution does not decompose so easily as those made with aniline 
oil. It should not, however, be over ten to fourteen days old. 

II. Decolorizing solution of nitric acid, and 
III. Contrast stain of methylene-blue, as above. 



DISEASES OF THE LUNGS AND PL EU RM. 



279 



The preparation and staining are exactly the same as in method A. 
The tubercle bacilli are stained red, the other bodies blue. 

C. Gabbett's method. 

Solutions Used. 

I. Carbolic fuchsin solution (as in B.). 
II. Methylene-blue solution: 

Methylene-blue 1 .... . 2 grammes. 

Sulphuric acid .... . 25 c.c. 

Distilled water 75 c.c. 

This solution is liable to decompose if old. 

Preparation of Slips and Staining. The cover-glass is prepared and 
stained with the carbolic-fuchsin solution and washed in water as in A. 
Then (instead of decolorizing with nitric acid or adding in contrast 
stain) the slip is washed for one half to two minutes in the methylene- 
blue solution, until a faiut blue replaces the red tinge in the (slip) 
sputum ; the excess of the solution is washed off with water, and the 
slip is mounted and examined as above. The tubercle bacilli are 
stained red and the other bodies blue. 

The writer has found that this method can be rapidly applied, and 
that it has given good results ; he recommends it highly. 

D. Gibbes' method. 

Solutions Used. 

I. a. Fuchsin 3 grammes. 

Methylene-blue 1 gramme. 

Mix thoroughly in a mortar. 

b. Aniline oil 5 c.c. 

Alcohol 20 c.c. 

Dissolve and add b to a slowly, stirring vigorously until a is evidently 
dissolved, then add 20 c.c. of distilled water and keep in a stoppered 
bottle, ready for use. 

Prepare slip aud stain with this solution, as with the others, up to 
the point of decolorizing. Then wash with alcohol until dye ceases to 
come away. Mount and examine as above. Tubercle bacilli will be 
stained dark red — the other objects dark blue. 

When the bacilli are few in number, Biedert proposes that the 
following preliminary steps be taken : About 4 c.c. of sputum are 
mixed with 8 c.c. of water and 1 c.c. of solution of caustic soda, and 
boiled a few minutes, when about 15 c.c. of water are added and the 
whole again boiled until a homogeneous fluid is formed. This is 
allowed to stand in a conical glass for twenty-four to forty-eight hours, 
when the sediment is stained by the Ziehl-Seelsen or Gabbett method. 
Or the homogeneous fluid can be put at once in a centrifugal machine, 
and the resulting sediment stained. 

Sputa have been hardened and sections made and stained for tubercle 
bacilli, but the method is not of special value. 

It is well to remember that in the absence of a proper decolorizing 
agent, hot water applied for some minutes has been shown to decolorize 
very satisfactorily. 

Importance. The greatest importance attaches to the presence or 
continuance of tubercle bacilli in sputa. It indicates tuberculosis 
of the lungs or larynx ; in the vast majority of cases, of the former. 

1 An alcoholic solution of methyl-blue should first be made, and then added drop by drop, with 
constant stirring, to the sulphuric acid and water. 



280 



SPECIAL DIAGNOSIS. 



They are often to be found in the sputum when physical signs are still 
absent or are indefinite. The number varies so greatly in different 
cases, and in the same case at different times, that in recent cases it is 
impossible to judge of the extent of the disease by the number present 
in a given preparation. 1 

The absence of bacilli from sputa has no true value unless negative 
results are obtained after many trials and careful examination by an 
experienced observer using good stains. Hence, too great care in each 
and every step cannot be taken. 

Biological Properties. The tubercle bacillus is difficult to cultivate, 
as it grows readily only in exact conditions found within the body. 
The best medium is blood-serum. The cheesy mass from the sputum 
or the tubercular nodule from a tissue is placed on the surface of the 
serum and rubbed carefully over it. It is best to make twenty or 
thirty such inoculations. The tubes must then be sealed to prevent 
evaporation and drying, and exposed for twelve days to a temper- 
ature of 87.5° C. When a pure culture is obtained, further cultiva- 
tions may be made on agar-agar to which 6 per cent, of glycerin has 
been added. 

The pure cultures appear as dry masses on the surface of the medium, 
either as flat scales or clumps of mealy-looking granules. They are of 
a dirty drab or brownish gray color. (See Plate II., Fig. 6.) The 
bacillus is parasitic, aerobic, non-motile (facultative anaerobic). 

Micrococcus Lanceolatus. Pneumococcus. Diplococcus Pneumonias. 
The causative factor of croupous pneumonia is in its typical form an 
oval coccus, with one end smaller and more tapering than the other. 
It may, however, be regularly oval, or spherical. It is 1 to 1.5^ in 
length, and one-half or one-third greater than its width. Forms occur 
in which the width is only one-half or one-fifth its length. It is thus 
really a bacillus, and is called such by many observers. Two cocci are 
usually found together, end to end, hence the term diplococcus ; and 
often two or three such pairs are arranged together to form a chain. 
These chains are at times not distinguishable from some varieties of 
streptococci, and there may be a close connection between them. The 
lanceolate cocci have a capsule, a fact which aids in the diagnosis of this 
bacterium more than the pair arrangement or lance-shape. (See Plate 

I., Fig. 1,B.) 

Pneumococci are stained in cover-glass preparations with the ordinary 
aniline dyes, as given above. The capsule may be stained and differ- 
entiated in the same way, but it more often requires a special method. 
Welch recommends the following : Spread and dried cover-glass prepa- 
rations are treated first with glacial acetic acid, which is allowed to 
drain off, and is replaced (without washing in water) with aniline oil- 
gentian-violet solution. (See under Tubercle Bacilli.) The staining 
solution is repeatedly added to the surface of the cover-glass until all 
of the acid is displaced. The specimen is now washed in a weak salt 
solution (about 2 per cent.), and examined in the same, not in balsam. 

1 A Method for the Examination of the Actual Number of Tubercle Bacilli in Tuberculous 
Sputum. By George H. F. Nuttall, M.D., Ph.D., The Johns Hopkins Hospital Bulletin, May, 1891. 
The method is of pathological but not of diagnostic interest. 



DISEASES OF THE LUNGS AND PLEURiE. 



281 



The capsule and coccus can then be differentiated. Degenerative and 
involution forms are constantly met with. There will be variations 
in size and shape, and the capsule may contain only remains of a 
coccus, or be entirely empty. 

The micrococcus lanceolatus is not motile, and never forms spores. 
It is facultative anaerobic. It grows in various alkaline media. Favor- 
able temperature 35° to 37°, death-point 57° C. The growth is very 
rapid in liquid media, rendering the fluid cloudy in six to twelve hours. 
After about forty-eight hours the multiplication stops and the micro- 
organisms settle, leaving the fluid clear. In gelatin stab cultures small 
white colonies form along the puncture. It does not liquefy the gela- 
tin. On agar it forms very characteristic jelly-like drops. 

By inoculation into susceptible animals a typical fibrinous pneumonia 
is developed. The pathogenic power attenuates rapidly in cultures, but 
recovers its virulence by passing through susceptible animals. 

This micro-organism is found in all cases of croupous pneumonia. It 
is also found in health in the saliva, in empyemas due to its presence, 
making a favorable prognosis, and in meningitis, ulcerative endocarditis, 
acute abscesses, otitis media, and arthritis due to it. 

Bacillus of Influenza. This micro-organism is found in purulent 
sputum. It was first detected by Pfeiffer. The bacilli have the form 
of minute rods, single or in chains of three and four, and stain well in 
Loffler's methylene-blue fluid and in the dilute Ziehl-Neelsen fluid. 
Cultivations have been made on glycerin agar. When solidified 
obliquely, separate colonies form, which, after twenty-four hours appear 
like drops of water visible only by a lens. In the blood they can be 
detected in cover-glass preparations after staining. After having the 
dried cover-glass preparation in an absolute alcohol bath for five 
minutes, then stain from three to six hours in eosin-methylene-blue 
fluid. (See formula.) 

Actinomyces. When the lungs or pleura are infected by this fungus, 
actinomyces will be found in the sputum. The disease in these organs 
is rare. Macroscopically they appear as small kernels, yellowish 
white or greenish yellow, and having the shape of a millet-seed. Under 
the microscope they are recognized by the rounded club-like bodies 
projecting from all sides of a central unformed mass. They are seen 
better when not stained. 

Chemistry of Sputum. As the chemical examination of the sputum 
does not aid us in diagnosis, it is of but little or of no value. Mucin, 
nuclein and serum albumin are constituents of sputa in health. Pep- 
tone is present whenever there is pus, and is specially marked in pneu- 
monia. Volatile fatty acids, such as butyric and acetic, occur at times, 
markedly so in pulmonary gangrene. Glycogen has been obtained by 
Solomon, and a ferment resembling one of the pancreatic ferments has 
been detected, especially in pulmonary gangrene and putrid bronchitis. 
Of inorganic substances, chlorides of soda and magnesia ; phosphates of 
soda, lime and magnesia; sulphates of soda and lime; carbonate of 
soda, lime and magnesia ; and in a few cases phosphate of iron and 
silicates rarely obtained. (Von Jaksch.) 



282 



SPECIAL DIAGNOSIS. 



The Data Obtained by Inquiry. 

The Subjective Symptoms. Dyspnoea. Dyspnoea, in its true 
sense, means difficult breathing. The respirations are deeper than nat- 
ural, but of normal frequency, or they may only be more frequent than 
they should be, or they may be both deeper and more frequent. The 
patient is usually conscious of suffering or of some distress in breathing. 
Lung disease without dyspnoea : While a common, indeed almost con- 
stant symptom of lung disease, it does not follow that because a patient 
has extensive disease of the lung he need suffer from difficult or hur- 
ried breathing. This arises because the demands of the system require 
no more air than the capacity of the lung is able to supply. The 
change takes place very gradually, but many persons with chronic 
fibroid phthisis, or with emphysema, in both of which the disease may 
be extensive, may not have dyspnoea, unless there are unusual demands 
upon their systems. The subjects are under- weight, move slowly, and 
otherwise show that they are deprived of an essential to active being. 

Variety of Dyspnoea depending upon Cause: 

I. Anything which cuts off or lessens the normal amount of air 
required for oxygenation of the blood. A. Obstruction of the air-pas- 
sages. B. Diminution of air-space from causes within and outside of 
the thorax. C. Interference with the action of the muscles concerned 
in breathing. 

II. Affections which lessen the amount of blood, as obstructive heart 
disease. Rarely, tumors pressing upon the bloodvessels. 

III. Affections in which the red blood-corpuscles are diminished — 
anaemia. 

IV. Pulmonary embolism and thrombosis. In cases of weak heart 
the vessels become occluded. After labor a clot of blood may escape 
from a uterine sinus, be carried to the right heart, and thence to the 
pulmonic veins. The clot may arise from inflammation of the veins in 
any situation. 

V. Foreign substances in the blood, as fat, occurring in parturient 
women three or four days after labor, after fractures, and in diabetes. 

VI. Dyspnoea due to interference with the nervous mechanism of 
respiration, a. Tumor, hemorrhage, or degeneration about the respira- 
tory centre in the medulla, b. Irritation of the centre by toxic agents, 
as in uraemia, diabetes, auto-intoxication from gastro-intestinal dis- 
order. To this class belongs "heat dyspnoea," which occurs in all 
febrile conditions. The warm blood acts as a direct irritant to the 
respiratory centre in the medulla oblongata (Landois). This explains 
the dyspnoea of fever and the curious fact pointed out by Cohnheim, 
that the respirations in pneumonia lessen as soon as the fever disappears, 
notwithstanding the persistence of the physical condition, on account 
of which the dyspnoea might have been explained. Reflex dyspnoea 
(asthma, q. v.) belongs to this variety. The dyspnoea of hysteria is of 
the same class. 

Anything which cuts off or lessens the normal amount of air re- 
quired for oxygenation of the blood. A. Obstruction of the air pas- 



DISEASES OF THE LUNGS AND PLEURA. 



283 



sages. 1. Occlusion of the nares, unless compensated for by mouth- 
breathing. 2. Enlargement of the tonsils, retropharyngeal abscess, 
or any obstruction in the throat, from diphtheritic or ©edematous swell- 
ing. 3. Disease of the larynx causing stenosis also causes a charac- 
teristic form of dyspnoea (see Disease of the Larynx). 4. Obstruction 
of the trachea or bronchus from external pressure or from a foreign 
body. Dyspnoea from the latter cause must be distinguished from 
dyspnoea the origin of which is higher up in the air-passages. Inspec- 
tion of the upper cavities usually reveals the cause. 

a. Tracheal Obstruction. In dyspnoea from occlusion of a bronchus 
or the trachea there is no increase in the movement of the larynx. 
There is no change in the voice, except that it may be weakened and 
the sonorous quality diminished. If, however, there is at the same 
time attendant disease of the larynx from syphilis, or paralysis of the 
muscles from pressure on the recurrent laryngeal nerves by the same 
cause which produces the tracheal stenosis, the voice will be modified. 
If so, on laryngoscopic examination the tumor pressing upon the larynx 
can be seen at times, especially if the larynx is healthy. Expert 
operators can secure a considerable view of the windpipe, particularly 
if the head is bent slightly forward and the patient is seated in the 
upright posture. A mirror must then be placed against the soft palate 
with the surface more horizontal than usual. By this means an aneur- 
ism may be seen bulging into the trachea. It must not be mistaken 
for pulsation of the lower end of the trachea due to transmission of 
the impulse of the aorta to the trachea, which has been shown to occur 
in healthy persons. 

The dyspnoea is expiratory and is never so extreme as in laryngeal 
stenosis. The lower ribs are therefore not sucked in during inspiration 
until late in the disease. A stridor attends the dyspnoea which is 
heard with the stethoscope over the trachea, as well as over every part 
of the chest. Sometimes a point over the trachea can be determined at 
which the sound is heard loudest. The point may indicate the seat of a 
stenosis. Sometimes the sound is more marked over the larynx than 
over the sternum when the lower part of the trachea is obstructed. 
Demme has pointed out that in cases of prolonged obstruction in the 
lower air-passages the upper portion of the thorax may diminish in 
size. The dyspnoea is not only constant, but paroxysms may also take 
place in which the distress is very severe. These paroxysms of dys- 
pnoea may be due to spasm of the vocal cords ; but it is very likely that 
they are due, as Bristowe has shown, to swelling of the mucous mem- 
brane or to mucus which has accumulated at the point of obstruction and 
cannot be dislodged, or to spasm of the muscular tissue of the trachea 
itself. In addition to the subjective symptom of want of breath the 
patient may complain of pain or oppression behind the sternum, or 
possibly only of a slight soreness. Cough usually attends the dys- 
pnoea, with expectoration of mucus. Sometimes the mucus is blood- 
tinged, and even streaks of blood may be expectorated after a con- 
siderable time, in cases of leaking aneurism. 

If the obstruction is due to a foreign body the dyspnoea occurs 



284 



SPECIAL DIAGNOSIS. 



b. Bronchial Obstruction. If a bronchus is obstructed the lung to 
which air passes freely becomes the seat of extensive emphysema. 
When obstruction takes place gradually compensatory emphysema 
occurs, developing slowly, not rapidly as in the former instance, the 
degree depending upon the amount of obstruction in the opposite bron- 
chus. When the bronchus is obstructed the physical signs are pro- 
nounced. The vesicular murmur over the corresponding side of the 
chest is absent, fremitus is absent, the movement of the affected side is 
impaired. With these changes the percussion sound is normal. As 
the case advances the affected side may fall in and measure less than 
the opposite side. A snoring or whistling sound may be heard over 
the root of the lung, between the scapula and vertebrae, or moist rales 
may be present. The causes of tracheal and bronchial obstruction are : 
first, tumor of the thyroid gland; second, thoracic aneurism; third, 
mediastinal tumor from other cause than aneurism, as disease of the 
glands, cancerous or tubercular, or mediastinal abscess ; fifth, cancer of 
the oesophagus; and, finally, in rare cases, a dilated auricle. But dis- 
eases of the walls of the trachea also cause obstruction by narrowing 
the calibre. Syphilis is the most frequent cause of such obstruction. 
Within the lumen the presence of a foreign body causes obstruction. 
The foreign body may remain free for a time, moving up and down as 
the patient coughs, and, indeed, it may be felt against the side of the 
trachea when the finger is placed outside the neck. Later the foreign 
body usually becomes fixed in the right bronchus, or one of its main 
divisions, because the opening of the right bronchus is more direct than 
that of the left. In some instances the body may be dislodged and fall 
into the opposite bronchus. Rarely it falls first into the left. 

B. Dyspnosa from Diminution of the Air-space in the Lungs. All 
forms of pulmonary disease attended by consolidation, by compression of 
the lung, or occlusion of the small bronchi, are included under this sub- 
division. The degree of dyspnoea of course depends upon the extent of 
the diminution in the air-space. In pleural effusions from any cause 
the air-space is lessened and dyspnoea occurs. In bilateral effusions it 
is more marked than in unilateral. The severity of the dyspnoea 
depends somewhat upon the rapidity with which the effusion takes 
place. In cases of sudden effusion of air, as in pneumothorax, the 
dyspnoea is very alarming at first, but as accommodation takes place 
it is gradually relieved. In rapid effusion of serum it is also serious. 

The characteristic form of dyspnoea due to lessened air-space is seen 
when obstruction of the air-tubes takes place on account of spasm. The 
attack comes on suddenly in the midst of quiet breathing (see Asthma). 
It occurs in paroxysms in asthmatic subjects. It may occur, however, 
on slight exertion, or it may in a measure be constant. But when the 
dyspnoea that is associated with asthma is constant other changes have 
taken place in the lungs. First, there is persistent bronchitis ; second, 
the presence of emphysema. Indeed, in many cases it is often difficult 
accurately to ascertain the sequence of affections. In emphysema of 
the lungs dyspnoea is constant, but on exposure to cold or on account 
of an attack of indigestion, more severe paroxysms may occur, and asth- 
matic attacks, although the patient is not an asthmatic. On the other 



DISEASES OF THE LUNGS AND PLEURAE. 



285 



hand, a patient may have had asthma for a long period of years, during 
which attacks of dyspnoea occur in paroxysms only. As time passes 
the paroxysms become more and more frequent, on account of which 
emphysema develops. With the advent of the emphysema the dys- 
pnoea becomes more constant. 

Asthma is a type of dyspnoea of nervous origin. It has just been 
said that it is due to spasm of the bronchial tubes. This may occur 
from a number of causes : (a) It may be of central origin, from irritation 
of the pneumogastric centre ; (b) it is just possible that some disturbance 
of the trunk of the pneumogastric nerve will also cause asthmatic 
dyspnoea ; but what concerns us most is (c) the paroxysmal dyspnoea 
which arises reflexly from irritation of the terminal endings of the 
pneumogastric nerve, or of nerves intimately associated with the pneu- 
mogastric, in the medulla. First. Disease in the upper air-passages, as 
polyps, or a hypertrophy of the turbinated bones, or adenoid growths, 
are the most frequent source of paroxysmal dyspnoea. Not only in 
permanent disease of this character do we have such dyspnoea, but 
temporary irritants applied to the nares likewise produce it. Various 
odors, the irritation of micro-organisms, or of pollen, or emanations 
from vegetable life, provoke attacks of nasal congestion and reflex dys- 
pnoea. The irritation is propagated through the ethmoidal and posterior 
nasal branches of the nerve, the Vidian and naso-palatine nerves to the 
septum, aud the anterior palatine to the middle and lower turbinates. 
Second. Irritation in the fauces and larynx is not so likely to cause 
dyspnoea, yet there is no doubt that the presence of a constant irri- 
tant in these situations tends to provoke, or keep in a state of 
excitability, the respiratory tract, so that asthma is more likely to 
persist. Third. To this class of cases belongs the irritation of the termi- 
nal branches of the pneumogastric nerve in the stomach. Peptic asthma, 
or the asthma of indigestion, may owe its origin to these causes. Often 
the irritation is central, due to the irritating influence of an abnormal pro- 
duct of indigestion upon the respiratory centres in the medulla. Fourth. 
For the same reason we have asthma due to other poisonous substances 
circulating in the blood, as the poison of uraemia. The dyspnoea due to 
this condition usually occurs in paroxysms, but may become constant. 
Sometimes it is the first intimation of the presence of renal disease. The 
dyspnoea of diabetic coma may occur from the same cause. The nature 
of both of them is recognized more particularly by their associate 
symptoms. The condition of the urine, the odor of the breath and the 
exhalations, the presence of hypertrophy of the heart and of an accent- 
uated second sound, point to a ursemic origin. The history and symp- 
toms of diabetes, the odor of acetone on the breath, the presence of sugar 
in the urine, the absence of organic disease, point to diabetes. The dys- 
pnoea of ursemia cannot be distinguished from other forms of dyspnoea, 
except by the exclusion of cardiac and lung disease. The latter is difficult 
often, because ursemia so frequently develop? after the hypertrophied 
heart has failed, so that the physical signs of dilatation may be sufficient 
to explain the dyspnoea. The dyspnoea of diabetic coma, known as "air- 
hunger," is characterized by slow and deep respirations. The Cheyne- 
Stokes respiration has for its source the same cause, namely, irritation 



286 



SPECIAL DIAGNOSIS. 



in the medulla, as in other forms of nervous dyspnoea. It must not 
be forgotten that the dyspnoea of uraemia may present the Cheyne- 
Stokes phenomenon. 

Diminution of Air-space from Extra-pulmonary Causes. Anything 
which crowds upon the thorax, interfering with pulmonary expan- 
sion, causes dyspnoea. In affections below the diaphragm, this 
is notably the case. Hence in enlargement of the various organs of 
the abdomen, as the liver, spleen, kidneys, pancreas (cystic disease), 
and uterus, dyspnoea always occurs. In accumulations of gas (flatu- 
lency), or of fluid (ascites), the diaphragm is pressed upward and 
encroaches on the thoracic capacity. In abdominal tumor, as of the 
ovary, the omentum, and of the organs above mentioned, dyspnoea is a 
distressing feature. 

C. Interference with the Action of the Muscles. Practically any de- 
rangement of the action of the respiratory muscles diminishes the air- 
space, as expansion of the lungs is interfered with. Nevertheless the 
cause of the dyspnoea is extra-pulmonary. It is due to weakness or 
paralysis of the muscles concerned in breathing, or to inhibition of their 
action on account of pain, or to interference with their action on 
account of obesity, myxoedema, or oedema, or on account of actual dis- 
ease, as in trichinosis or myositis. 

1. Phrenic dyspnoea is a peculiar form due to paresis of the phrenic 
nerve and consequently to interference with the action of the diaphragm. 
It may not be observed as long as the patient is at rest. Upon slight 
exertion the effort distresses him and causes an increase in frequency of 
the respirations. After a few steps a sense of suffocation ensues, or 
upon ascending an elevation the patient must stop frequently to take a 
breath. 

Other physiological processes are affected in phrenic dyspnoea. In the 
act of sighing the patient feels as though the abdominal organs were 
drawn up into the chest. Any straining effort, as at defalcation, is 
embarrassed. The voice is weak, and there is difficulty in coughing and 
sneezing, because a full inspiration cannot be taken. A slight attack 
of bronchitis may be very serious on this account. On inspection 
during inspiration, instead of the natural expansion of the ribs and 
chest, the epigastrium and the hypochoudriac regions are drawn in. 
During expiration they are pushed forward. The thoracic movements 
are reversed. The abnormality may be detected on palpation with 
both hands below the cartilages of the ribs, even better than by 
inspection. Unilateral paralysis of the diaphragm causes drawing in 
of the corresponding hypochondriac region. 

In progressive muscular atrophy, in general lead-poisoning, and in 
multiple neuritis from other causes, paralysis of the diaphragm may 
take place. It is said to occur in hysteria, and Walshe states that he 
has seen it after diphtheria. In fatty degeneration of the diaphragm, on 
account of inflammation extending from the peritoneum to the pleura, 
the same phenomenon has been seen. It may occur in trichinosis. 

Paralysis must be distinguished from inaction of the diaphragm. 
When the drawing in during the act of inspiration of one or 
both hypochondriac regions occurs it is diagnostic of the occur- 



DISEASES OF THE LUNGS AND 



PLEURAE. 



287 



rence of inaction rather than paralysis ; whereas paralysis of other 
muscles, with a distinct cause for paralysis, is found with the latter 
condition. 

The dyspnoea that occurs from paralysis of other respiratory muscles 
can be recognized on careful inspection and palpation. The atrophied 
groups of muscles are readily observed. Electricity may aid in the 
diagnosis. 

2. Pain inhibits muscular action. The source of the pain may be in 
the pleura, the muscles, or the intercostal nerves. Frequently it is 
below the diaphragm, as in peritonitis, hepatitis, etc., interfering with 
the action of that muscle. The dyspnoea that occurs from pain, as 
pleuritis, or inflammation of the chest wall, is recognized by the posture 
which is taken in order to relieve the affected side, by local tenderness, 
and by the physical signs of pleurisy or of pleurodynia. 

Clinical Varieties. We observe whether dyspnoea is (a) modified by 
exertion, (6) attended by alteration in the respiratory rhythm, (c) is 
constant or paroxysmal. 

(a) Influenced by Exertion. 1. Shortness of breath may be apparent on 
exertion only, as in cases of simple debility, or of interference with 
respiratory action on account of obesity. It is the form of shortness of 
breath seen in anaemia and in moderate cardiac debility. It may not be 
observed by the patieut unless he walks hurriedly or ascends a flight of 
stairs. 2. Shortness of breath independent of exertion is of more serious 
import, and is due to a number of causes. It is the shortness of breath 
that is seen in severe cardiac and pulmonary disease. To the latter 
belong asthma and emphysema, bronchial obstructions, pulmonary con- 
solidation and compressions (by effusions). 

(6) The Mate of Respiration. Dyspnoea varies clinically, depending 
upon the frequency of the respiration. In its most extreme form it is 
known as orthopnoea, when the upright posture of the trunk is assumed. 
(See Posture.) 

1. Dyspnoea with respiration slow or normal, a. Dyspnoea may be 
characterized by deep inspirations, the frequency of respiration being 
less than normal. This is one of the forms of dyspnoea seen in 
diabetic coma — u breathlessness without dyspnoea." It is most char- 
acteristic, and associated with nausea, vomiting, and coma, while the 
breath and urine smell of acetone, b. The breathing may be slow and 
stertorous. Such breathing is likewise associated with coma, but the 
coma is of central origin, due chiefly to apoplexy or tumor. 

2. Irregular respiration. Alternately slower and shallower breath- 
ing, and then quicker as well as deeper, is seen in the peculiar form of 
breathing known as the Cheyne-Stokes respiration. It includes a period 
of apnoea, and at the same time alterations in the size of the pupils. (See 
Ursemia and Diseases of the Brain.) 3. Respirations increased. The 
respirations may be hurried and create distress in simple nervousness 
alone, and hurried respiration is quite common in cases of hysteria. 
Often in the latter instance the frequent breathing is not attended by 
distress to the patient. The respirations are panting in character, and 
are half the normal pulse rate or even as much as the pulse. The 
term panting is applied to such respiration at times. The same character 



288 



SPECIAL DIAGNOSIS. 



of breathing is seen in exophthalmic goitre. The rate of respiration 
is increased in all forms of dyspnoea upon exertion (see above), and all 
forms due to heart or lung disease. It may be observed that slow 
respirations with dyspnoea are usually central or toxic. Toward the 
end of life the respirations, even though hurried before, become slower 
from carbon dioxide intoxication. 

(c) Dyspnoea may be further divided clinically into constant and 
paroxysmal dyspnoea. Constant dyspnoea implies a persistence of the 
cause. Paroxysmal dyspnoea does not include the form that is in- 
creased by exertion — a form which in one sense may be paroxysmal. 
It is seen in its most typical form in asthma. It is often of cardiac 
origin, or may be due to central or reflex causes. It occurs usually at 
night. Constant dyspnoea is frequently subject to aggravations par- 
oxysmal in occurrence. Asthma is the type of true paroxysmal 
dyspnoea. 

Diagnosis. While dyspnoea is usually easy of recognition, it must not 
be forgotten that attacks of acute indigestion with thoracic symptoms of 
oppression may simulate the oppression of dyspnoea. It is temporary, 
however, and not associated with increased rapidity of the respiration. 
Dyspnoea is recognized by increase in rapidity of chest movement, with 
increased action of all the muscles of respiration, both the essential and 
the auxiliary muscles. At the same time the expression is pronounced. 
The alee nasi move, the eyes and countenance are indicative of more 
or less agony, the pupils are dilated. As the dyspnoea continues 
cyanosis develops, and frequently a cold sweat breaks out. This may 
be limited to the forehead and face and to the extremities, or may be- 
come general. The hands and feet become cold. Stupor sets in, carpo- 
pedal spasm or general convulsions follow, the respirations become 
slower, and death takes place in coma or from heart failure (asystole). 

The dyspnoea of emphysema is characteristic. The difficulty is seen 
to be due to the inability to empty the chest of air (expiratory dyspnoea). 
The inspiration is short and quick ; the expiration is prolonged, and all 
the auxiliary muscles are called upon to complete the act. The power- 
ful abdominal muscles are seen to contract vigorously, and thus aid in 
pressing up the diaphragm. The quadratus lumborum and serratus pos- 
ticus superior et inferior draw down the ribs. The scaleni are strongly 
contracted, the serratus magnus, latissimus dorsi, and the pectorales all 
aid in elevating the ribs. Knowledge of the processes involved in 
forced expiration render the diagnosis comparatively easy. The con- 
traction of the broad abdominal muscles confirms the diagnosis. 

Cough in Pulmonary Affections. (See Larynx.) Coughing is 
a reflex act. A deep inspiration is taken, followed by closure of the 
glottis, succeeded immediately by a sudden expiratory effort during which 
the glottis is opened, causing a loud sound with the forcible passage of air 
outward, along with any substances in the air-vessels. The pulmonic 
irritation, on account of which the act takes place, usually starts in the 
respiratory mucous membrane. The cough is then used to expel accu- 
mulations of mucus or pus, or foreign substance. It occurs in all forms 
of bronchitis and in the lung affections generally in which bronchitis is 
associated. The cough of phthisis, if not laryngeal, is due to a local- 



DISEASES OF THE LUNGS AND PLEURA. 



289 



ized bronchial catarrh. Nodules outside of the bronchi, situated in the 
lung substance, do not provoke the act of coughing, as we see in the cal- 
careous and fibrous nodules of healed tuberculosis. The irritation is 
not limited to the mucous membrane of the bronchial tubes but occurs 
in the mucous membrane of any portion of the respiratory tract. A 
foreign body of any kind in the bronchus sets up cough. It is notably 
present in pharyngeal and laryngeal diseases. The cough of the latter 
is of peculiar character, which renders it easily distinguished from cough 
due to other causes. Cough may also occur from causes outside of the 
air-passages. It may be of centric origin. Kohts has found by experi- 
ment that irritation of the floor of the fourth ventricle above the centre 
for respiration excites a cough. It is possibly on account of this centric 
origin that we may explain the cough of hysteria and the short barking 
cough which arises in hysterical or nervous states when the patient is 
afflicted with the idea that he is about to have hydrophobia. Irritation 
of nerves which are in anatomical relation with the pneumogastric also 
excites cough. The most characteristic cough of this form is that due 
to the presence of a foreign body in the meatus of the ear, or to disease 
of that organ. It is sometimes difficult to examine the external audi- 
tory meatus, because coughing is excited. The afferent nerve which 
receives the irritation is the auriculotemporal branch of the fifth nerve, 
according to Dr. Fox, and not the minute auricular twig of the vagus. 

Tooth Cough. The same authority points to the occurrence of cough 
from the irritation of the stump of a tooth, and refers to cough in 
infants during the first dentition. 

Stomach Cough. The popular opinion that cough is very frequently 
due to the stomach is not substantiated by the experiments of Kohts. 
We, nevertheless, have a cough very frequently with patients who are 
suffering from mild gastric catarrh, the treatment of which relieves the 
cough. This is in all probability due to the fact that with the gastritis 
there is a secondary pharyngitis, and as the former is relieved the latter, 
which causes the cough, disappears entirely. 

It will be seen, therefore, that when investigating the cause of a 
cough in diseases in which this symptom is prominent it is necessary 
not only to make examination of the respiratory tract throughout its 
course, but also to examine the condition of the ear and the teeth, and 
to bear in mind its possible centric origin. 

Clinical Characteristics. The cough may be dry or moist. 1. A dry 
cough occurs when there is an irremovable source of irritation. (See 
dry cough of laryngeal disease.) It is seen in the first stage of bronchitis. 
It occurs in the earlier stages of phthisis. As a short, hacking, sup- 
pressed cough it occurs in pleurisy in the first stage. In the second 
stage it is superficial, as if the sound waves were checked. It is char- 
acteristic and most familiar, although described with difficulty. It is 
particularly the type of cough due to irritation outside of the respira- 
tory tract. The ear cough and tooth cough partake of this character. 
In cases of emphysema the cough may be dry and unproductive 
for a long time, and only be relieved after a small pellet of tough 
mucus is discharged. In the same category belongs the nervous cough 
which occurs from bad habit, the cough of hysteria, and the cough 

19 



290 



SPECIAL DIAGNOSIS. 



of a peculiar barking character that occurs at puberty, which Sir 
Andrew Clark has described. 

2. The moist cough is attended by expectoration of a mucous, muco- 
purulent, purulent, or bloody character, which is comparatively easily 
removed. Dry and moist or loose cough may be either constant or 
paroxysmal, or both. The moist cough may occur in paroxysms only, 
each paroxysm being relieved by the removal of the irritation, the 
subsequent paroxysm not taking place until the irritating secretion has 
reaccumulated. In cases of bronchitis of the second stage paroxysms of 
cough may occur every few hours, or the cough may take place once in 
the twenty-four hours, usually in the morning on arising. The accumu- 
lated secretions of the night are disposed of, and then the patient 
remains free from annoyance. In some circumstances the cough is 
almost constant. The irritation is constantly present. A large amount 
of secretion is rapidly poured out, keeping up a constant cough. This 
is seen in bronchorrhoea and bronchial dilatation and in the later stages 
of tuberculosis. In these affections the moist cough may occur three or 
four times in twenty-four hours, during which time an enormous amount 
of sputum is thrown off. The cavity is thereby emptied, the accumu- 
lation of matter in which excites coughing only after a certain level is 
reached. In this affection the cough is further characterized by aggra- 
vation on change of position. In pertussis the character of the 
cough is of special diagnostic significance. In this affection the cough 
occurs in paroxysms. The expiratory efforts are frequent and rapid, 
followed by a noisy, prolonged inspiration, during which the character- 
istic whoop is created. At the same time the appearance of the counte- 
nance is marked. The face is cyanosed, the eyes stare, the appearance 
of distress is most striking. The labored efforts at coughing frequently 
terminate in an attack of retching or vomiting. 

It must not be forgotten that the presence of an irritant does not 
always excite cough. Thus when the reflexes are obtunded, as in 
typhoid fever, in disease of the brain, or in the last stages of any dis- 
ease, the presence of mucus will not excite cough, and yet it is known 
to be in the trachea, on account of the rattling which takes place. In 
cases of phthisis, sudden checking of the cough and expectoration, on 
account of weakness, is of bad prognosis and denotes approaching death. 
It is also a bad sign in pneumonia. 

The Sound. The character of the sound of the cough is usually 
modified by the condition of the larynx, for which reference must be 
made to the section on laryngeal diseases. 

The diagnostic significance of cough is estimated by the character ; 
by the sound ; whether constant or paroxysmal ; by the frequency of 
the paroxysm ; by its development at particular times or under par- 
ticular circumstances, as on rising in the morning, or change to a cold 
atmosphere, or speaking, or upon movement, as in phthisis. By the 
sound, laryngeal and bronchial coughs are distinguished. Constant 
cough implies a persistence of the cause, which is strictly pulmonary, as 
in pleurisy, phthisis, bronchitis, and consolidations generally; par- 
oxysmal, a recurrence of cause when pulmonary, or a reflex or central 
cause. Paroxysmal coughs occur in cavities, either of the lung or of 



DISEASES OF THE LUNGS AND PLEURAE. 



291 



the pleura opening into the lung. Cough is excited whenever the 
cavity fills with secretion. The paroxysm may occur daily or several 
times a day. Paroxysmal cough occurs in bronchitis after a certain 
amount of secretion accumulates. It is the cough of irritation outside 
of the lung, excited by reflex influences. The association with retching 
and vomiting is of some diagnostic significance. It is not only seen 
in whooping-cough, but is of frequent occurrence in phthisis. The 
value of cough in diagnosis is enhanced by knowledge as to the dura- 
tion of the cough and by the character of the expectoration. (See 
Sputum.) 

Hemorrhage. Hemorrhage of the lungs occurs from disease or 
from rupture of adjacent bloodvessels into the air-passages. It is not 
alone a symptom of lung disease. A hemorrhage may be small in 
amount and continue over a considerable period of time, or it may be 
characterized by a sudden profuse discharge, which at once terminates 
the life of the patient. 

Cause. A. Affections of the lungs. 1. Anything which causes 
congestion of the lungs will lead to hemorrhage. In this instance the 
amount of blood is small. It may be limited to streaking of the expec- 
toration, or a few mouthfuls may be discharged. In (a) organic heart 
disease this form of hemorrhage is seen. It is also a characteristic 
feature of the first stage of (b) croupous pneumonia. The rusty-colored 
sputum is due to the rupture of the capillaries. In (c) hemorrhagic in- 
farcts hemorrhage occurs, and, with the sudden formation of a con- 
solidated area in the lung, is diagnostic. In (d) phthisis it also occurs 
(see below). 

2. Tuberculosis. In tuberculosis hemorrhage may occur either (1) as 
the first symptom of the disease, on account of collateral congestion 
around infiltrated areas, or (2) later, on account of ulceration of an 
artery when excavation of the lung has taken place. In the early stages 
the hemorrhage is usually profuse, but not fatal. It may occur repeat- 
edly during a series of weeks, excited no doubt by the violent non- 
productive cough which attends the earlier stages of this disease. In 
the later stages, when the vessels are ulcerated, the patient may have 
repeated hemorrhages, varying from a few ounces to half a pint or a 
pint. They may occur daily, or be repeated at intervals of a week or 
more for a long period of time. After the hemorrhages that occur at 
long intervals the patient experiences much relief. Indeed, the dys- 
pnoea, cough, and chest oppression subside in a remarkable degree, and 
the occurrence of another hemorrhage is often predicted by gradual 
recurrence of these symptoms. Death does not usually ensue on ac- 
count of the large hemorrhage from phthisical ulceration, and yet it 
may possibly take place. The writer has seen four instances of hemor- 
rhage into a large cavity, in three with external hemorrhage also, which 
caused death instantaneously. 3. Hemorrhage recurring frequently is 
significant of cancer of the lungs, in the absence of other causes. 4. It 
is of common occurrence in plastic bronchitis, when large bronchial 
casts are expelled. 5. In gangrene of the lung it frequently occurs, 
often causing death. The odor and sputum indicate the true nature of 
the primary lesion. 6. Hemorrhage with the expectoration of calca- 



292 



SPECIAL DIAGNOSIS. 



reous masses occurs and recurs frequently in patients with healed or 

quiescent tubercle. 

B. Disease outside of the respiratory tract. (1) Aneurisinal disease 
of the bloodvessels which have intimate relation with the trachea and 
bronchus frequently causes ulceration into these tubes with the occur- 
rence of hemorrhage. The hemorrhage is usually profuse and often 
induces sudden death. Sometimes the profuse hemorrhage may be pre- 
ceded for days by small hemorrhages. The physical signs of aneurism 
are sufficient to explain the cause of the hemorrhage. The bleeding 
can sometimes be seen in the trachea when an aneurism of the innomi- 
nate artery or the aorta presses upon that tube. (2) In diseases of the 
heart it does not take place generally until the later stages of the dis- 
ease, and is associated with secondary congestion of the lungs. It may, 
however, be an early symptom in mitral stenosis. The hemorrhages 
may amount only to staining of the sputum,, or several times during 
the day an ounce or more of blood may be expectorated. 

C. Affections of the blood or bloodvessels with hemorrhages in other 
portions of the body. Thus, it may occur in haemophilia, in the forms 
of purpura, in scurvy, and in anaemia. It occurs in jaundice with 
hemorrhages in other situations. 

D. Gouty endarteritis. In the aged in both sexes, hemorrhages take 
place independently of disease of the heart or of the parenchyma of the 
lungs. Sir Andrew Clark and others have spoken of these hemor- 
rhages and attributed them to gouty changes in the vessels as well as to 
degenerations of lung tissue, on account of which the rupture took 
place. 

E. Without known cause. In certain instances pulmonary hemor- 
rhages occur in which it is quite difficult to find any cause for the 
discharge. It is quite common to see hemorrhage occur in females : 
sometimes at the menopause, in other cases during menstruation, or, 
again, perhaps vicariously when menstruation does not occur. A 
number of cases that have been under the writer's observation have had 
this tendency for years without the development of pulmonary disease, 
and, apparently, without much influence on the general health. Indeed, 
it may be said that hemorrhage from the lungs in women, other things 
being equal, is not of grave significance. 

The Symptoms. The only symptom may be the presence of blood in 
the expectoration, or the discharge of a small amount of blood with 
slight cough. In either instance, unless the patient's mental condition 
is rendered obtuse by disease, the hemorrhage is alarming to him. 
Much perturbation is created, and with other nervous phenomena, 
palpitation of the heart may take place. Apart from the nervousness 
excited by the sight of the blood, small hemorrhages, and even hemor- 
rhages of moderate amount, do not cause any other symptoms. The 
symptoms of a large hemorrhage depend upon the amount of blood 
that is lost. They may amount to faintness and giddiness only, or 
with them pallor may ensue. If more pronounced, syncope may take 
place ; extreme pallor develops ; the pulse becomes rapid, small, and 
feeble; the extremities are cold, and the face bathed in perspiration. If 
the syncope is recovered from, the patient is extremely restless, sighing 



DISEASES OF THE LUNGS AND PLEURA. 



293 



and breathing hurriedly. There may be some nausea. Moderate de- 
lirium and mild febrile symptoms often follow the restlessness. If the 
hemorrhages do not recur and the patient's fears are calmed, the color 
will gradually return and the heart's action become stronger and 
slower. These symptoms occur whether the hemorrhage is due to dis- 
ease of the lungs or to aneurism rupturing into the bronchus. If the 
hemorrhage is large they differ somewhat in the two conditions. If a 
large aneurism ruptures, the blood rapidly wells up into the throat 
and pours out through the nostrils and mouth with great rapidity. 
With such hemorrhage the fatal end may come in a few minutes. In 
pulmonary hemorrhages the discharge is not so profuse, and is attended 
by the act of coughing. With each cough blood is raised to the amount 
of a full mouthful at a time. The blood discharged from the lungs is 
bright in color, very frothy, being mixed with air. There are no clots 
in the discharged fluid. The blood from an aneurism is also bright 
red, but is not frothy, unless the discharge is very slow, and becomes 
mingled with air in the vessels. In rare cases of pulmonary hemor- 
rhage an abundant stream of blood pours out, which is dark in color, 
free from clots, and without mixture of air (large cavity). 

Diagnosis. Hemorrhage from the lungs must be distinguished from 
hemorrhage from the upper air-passages and from the stomach and 
oesophagus. Thus a discharge of blood from the mouth may occur from 
cracks in the pharynx, or varicose veins. It is not abundant and the 
hemorrhage is mingled with mucus, which is streaked with the blood. 
Hemorrhage from the gums may be taken for pulmonary hemorrhage, 
but if there is no stomatitis or inflammation of the gums from scorbutus 
or ptyalism, the source of the blood can easily be traced. In stomatitis 
its color is somewhat different. It is thin, fluid blood, often offensive, 
of cherry -juice color. Hemorrhage from the lungs is distinguished 
from hemorrhage from the stomach by the difference in the method 
in which it is discharged, aud difference in the character of the blood. 
In hemorrhage from the stomach the blood is vomited. It is mixed 
with particles of food or other gastric contents. It is dark in color, 
often of the appearance of coffee-grounds; it is not mixed with air, 
and hence is not frothy. The rapid hemorrhage from ulceration of an 
aneurism into the oesophagus, or rupture of varicose veins at the lower 
end of the oesophagus, cannot be distinguished from the hemorrhage 
that occurs when the aneurism ruptures into a bronchus. The recog- 
nition is dependent upon the physical signs and the previous history of 
the patient's illness. 

Pain. Pain is rarely a symptom of disease of the lungs unless 
the pleura is involved. In a case of bronchitis there may be some sore- 
ness and oppression behind the sternum, but otherwise pain is absent. 
In pleurisy, pain occurs before the exudation. The pain is sharp and 
lancinating, and so severe as to impede respiration and cause the cough 
to be short and catchy. It is usually seated at the base of the chest in 
the lateral or anterior region. It occurs when the patient attempts to 
take a full breath. Before the inspiratory excursion is half completed it 
is checked involuntarily on account of the pain. The patient's hand is 
placed upon the affected part and he involuntarily leans to that side. 



294 



SPECIAL DIAGNOSIS. 



The pain of pleurisy may be increased by local pressure, but general 
pressure, as from the whole hand, a broad bandage, or a large strap 
of adhesive plaster always gives relief. In the pleurisy that attends 
phthisis the pain is quite common. It is of the same character as the 
pain of acute plastic pleurisy, but varies in situation and in degree. The 
pain occurs in paroxysms. It follows a slight exposure to cold, undue 
exertion, or fatigue. It may continue for twenty-four hours, to remain 
away until a repetition of the cause institutes it again. It must 
be distinguished from the myalgia of phthisis due to cough and ex- 
posure. In myalgia, the muscles and fascia? at the bony attachments 
are very tender. 

The pain of pleurisy must be distinguished from pleurodynia, from 
intercostal neuralgia, and from the pain due to disease of the ribs. In 
pleurodynia the muscles are sensitive if pressed between the fingers or 
palpated. An enlarged area is affected, but physical signs of pleurisy 
or pneumonia cannot be elicited. Cough is absent, and so usually is fever. 
It is associated with pain in other muscular or fibrous structures. There 
may be a history of exposure to cold and dampness preceding it. Usually 
there is a history of lithaemia or frequent myalgia in the patient. Inter- 
costal neuralgia is sometimes difficult to distinguish. The pain is sharp, 
localized, and may modify the movements of the chest. General pres- 
sure relieves it, local pressure at the points where the terminal filaments 
of the nerve come to the surface may be detected. The so-called Val- 
leix's tender points are, however, not always present in cases of intercostal 
neuralgia. The patient is usually anaemic, often the subject of uterine or 
other exhausting disease, and may suffer from neuralgia in other situa- 
tions. Cough and physical signs are absent. Fracture of the ribs 
or caries of the rib may be recognized by the local tenderness, and by 
the signs of these conditions. Localized pleurisy may attend both, 
however — indicated by more severe pain on cough or full breathing. 
Caries or fracture is determined by pressure upon the diseased rib, and 
by the crepitus of fracture. An empyema that is about to point will 
cause pain in some area of the chest. The pain usually is seated at the 
points of election for the discharge of the empyema, and is soon fol- 
lowed by swelling, with heat and redness of the skin, and the occur- 
rence of oedema. 

More or less constant pain at the apices, undoubtedly independent of 
affections of the muscles, is a suspicious sign of tuberculous disease in 
that situation. It may be aggravated by pressure. 

Special Diagnosis. 

Diseases of the Bronchi. Diseases of the bronchi are distinguished 
from other diseases of the lungs chiefly by the difference in the physical 
signs. Except in capillary bronchitis, the general and subjective symp- 
toms are not so severe as in other affections. 

We are aided in the recognition of bronchial affections, first, by the 
fact that they are bilateral ; second, that the bases are usually affected ; 
third, that there is diminution of fremitus determined by palpation ; 



DISEASES OF THE LUNGS AND PLEUEJ1. 



295 



fourth, that there is absence of dullness on percussion; fifth, that rales are 
more pronounced in proportion to other physical signs, and more gen- 
eral than in other lung affections. 

Bronchitis. 

Bronchitis is an inflammation of the mucous membrane of the bron- 
chial tubes. It may be acute or chronic, may involve any part of the 
bronchial tree, the large, the middle-sized, or the most minute branches, 
and may be primary or occur secondarily to some general disease or to 
disease of the heart or kidneys. 

1. Acute Bronchitis occurs most frequently by extension of the 
catarrhal inflammation from the nose and throat ; but in some persons 
it develops so suddenly that it appears to be primary in the tubes. 

When the larger or middle-sized tubes are involved the patient com- 
plains of soreness or rawness underneath the sternum, especially at its 
upper part. There is frequently a feeling of tickling in the throat, and 
a sense of weight or oppression on the chest. Chest pain is due to my- 
algia or the strain upon the muscles from coughing. The cough is at 
first hard and dry, and often produces pain of a tearing character in the 
muscles of the chest or abdomen. The cough is apt to be worse when 
the patient first lies down, and again on rising, especially after a night's 
rest. Fever is usually slight and of short duration. The respirations 
are accelerated, but not markedly, and dyspnoea does not exist. The 
expectoration is at first a white, frothy, viscid mucus, subsequently be- 
coming more abundant and muco-purulent. 

Physical Signs. In uncomplicated cases there are no changes in the 
physical structure of the lungs. On examination of the chest, the per- 
cussion note is found to be clear; the respiratory murmur more rough- 
ened and harsh than normal, but not broncho- vesicular or bronchial ; 
accompanying breathing there are heard sibilant and sonorous rales, 
and, in the later stages, some large and medium- sized mucous rales. The 
rales vary in position from time to time, and especially after coughing. 
Vocal resonance and fremitus are unaltered. A fremitus may be pro- 
duced by sonorous rales. 

The cough and expectoration usually last for some time after fever 
has subsided. The duration of the disease is from a few days to sev- 
eral weeks. It is never fatal except in the very old and very young, 
or in those who are much debilitated. 

The diagnosis of acute bronchitis is easily made by noting the fact 
that the disease runs an acute course, marked by fever, cough, and ex- 
pectoration ; and that the physical signs are negative except as to 
roughening of the respiratory murmur and the existence of bronchial 
rales heard on both sides of the chest. 

From croupous pneumonia and local tuberculosis of the lungs it is 
distinguished by the absence of dulness on percussion, bronchial 
breathing, and increase of vocal resonance and fremitus ; by the absence, 
in other words, of the ordinary signs of consolidation. From pneu- 
monia it is further to be distinguished by the milder character of the 
subjective symptoms and by the fact that in bronchitis the physical signs 



296 



SPECIAL DIAGNOSIS. 



are almost always bilateral, in pneumonia generally unilateral. From 
tuberculosis it is further to be distinguished by the slow progress of the 
latter, which involves the apices preferably, whereas bronchitis is more 
marked at the bases ; and by the occurrence sooner or later of hectic fever 
and emaciation, which are absent in brouchitis. Doubt will exist usually 
only at first ; the progress of the case will in time make everything clear. 
Systematic examination of the sputum is an important diagnostic aid, 
and will lead to the differentiation of many cases of bronchitis from 
tuberculosis and from pneumonia. In infants and children especially, 
bronchitis is at times so rebellious to treatment that tuberculosis is 
suspected. 

In broncho-pneumonia (catarrhal pneumonia) there is a diffuse bron- 
chitis associated with small areas of pneumonic consolidation. It is to 
be distinguished by the graver general symptoms and by detecting small 
areas presenting dulness on percussion aud bronchial breathing, asso- 
ciated with the physical signs of bronchitis already described. 

Acute miliary tuberculosis of the lungs is very liable to be mistaken 
for bronchitis, because dulness, if present, amounts to nothing more 
than tympanitic dulness, because the signs are diffused through both 
lungs, and the respiratory murmur is fainter than normal but only 
slightly roughened. Close inspection of the patient will, however, 
make it evident that he is more ill than could be accounted for by bron- 
chitis alone. The fever is higher, the respirations more frequent, pallor, 
with a dusky or faintly cyanotic hue intermingled, is common, perspira- 
tions are more pronounced. A primary focus for the process may be 
discovered or a source of infection ascertained. 

Acute bronchitis may be mistaken for spasmodic laryngitis (croup). 
It is to be distinguished by the less amount of spasm and by the pres- 
ence of fever in addition to the physical signs. In bronchitis the 
breathing is rarely so stridulous as in laryngeal spasm. 

Whooping-cough cannot be distinguished positively from bronchitis 
before the characteristic whoop appears ; but it may be suspected when 
the child has been exposed to contagion, and when the coryza and red- 
ness of the fauces persist in spite of treatment. 

In the diagnosis of bronchitis it is often more difficult to determine 
the primary cause of it than to distinguish it from other pulmonary 
affections. The former is most important. It needs to be borne in 
mind that bronchitis is a frequent accompaniment of many febrile dis- 
eases, such as typhoid fever, measles, and whooping-cough ; of diseases 
of the heart and kidneys, and of septic diseases and blood disorders. 
The primary will not be likely to be mistaken for the secondary dis- 
order if one is upon his guard and insists upon finding a cause for each 
case that presents itself. 

Measles can be diagnosticated from the first usually by the coryza, but 
especially by the red spots upon the anterior half-arches of the soft 
palate, which appear usually several days before the eruption. 

Bronchitis is a common and important early symptom of typhoid 
fever. The latter disease may be suspected when the fever, prostration, 
and headache are greater, and especially if these symptoms coexist with 
a loose condition of the bowels, chilliness, aud occasional nose-bleed. 



DISEASES OF THE LUNGS AND PLEURAE. 



297 



2. Capillary Bronchitis, or Suffocative Catarrh, is bron- 
chitis of the smaller tubes. It occurs most frequently as the result of ex- 
tension of the catarrhal process from the larger tubes, but sometimes seems 
to attack the smaller tubes from the beginning, or coincideutly with the 
larger tubes. Infants, young children, and the aged are more liable to 
it. It begins with a succession of chills or chilliness, followed by high 
fever. The temperature may rise to 104°. The skin is hot, the face 
flushed. The head and neck and the upper portion of the trunk may 
be covered with perspiration. The pulse is rapid and soon increases to 
great frequency. 

The aspect of the patient from the first shows that the illness is 
graver than that of ordinary bronchitis. The face expresses anxiety, 
and in children the alse nasi play in respiration, which is both consider- 
ably accelerated and difficult (dyspnoea). The respirations may run as 
high as 60 or 80 to the minute, the pulse not being correspondingly 
frequent Dyspnoea is more or less constant, but becomes urgent in 
paroxysms, and the patient may need to be propped up in bed in order to 
breathe (orthopnoea). It is expiratory: inspiration may be free and 
easy, or it may be difficult, but expiration is always difficult aud pro- 
longed. In children the pause in the act of breathing takes place at 
the end of inspiration, instead of expiration. 

Cough is more frequent aud violent than in ordinary bronchitis, and 
the expectoration viscid and difficult to raise. As the disease progresses 
dyspnoea becomes more intense, and signs of deficient aeration of the 
blood make their appearance (cyanosis). The lips and finger-nails be- 
come bluish, and the extremities cool and clammy. If the patient is 
unable to expel the tenacious secretions from his bronchial tubes the 
further progress of the case is that of rapidly developing cyanosis ; the 
breathing continues frequent, but is shallow aud more labored. Chil- 
dren are liable to have convulsions, followed by coma and death, while 
old persons sink into coma without preceding convulsions. 

On the other hand, if the case is favorable, the patient's strength is 
maintained, and he is able to cough hard aud expectorate, consciousness 
is unclouded, and cyanosis does not become marked. 

The physical signs are those of bronchitis of the larger and smaller 
tubes ; sibilant and sonorous rales, if present at first, give way to fine 
subcrepitant and crepitant rales, which speedily become moist and very 
abundant. As in ordinary bronchitis, the bases of the lungs poste- 
riorly are the parts most involved. The percussion note remains clear 
over both lungs, but there is apt to be increased resistance. The fremitus 
may be lessened in some areas, increased in others. If an area of dulness 
appears it may be due to pneumonia or collapse of the lung; if the 
former, there is usually an access of fever. 

The sputum contains mucus, pus, occasionally blood-cells, granular 
matter, and sometimes fibrinous casts of the tubes. 

3. Chronic Bronchitis occurs most frequently in middle or later 
life. Its special features are its long duration, without fever, and with 
comparatively little impairment of the general health. Cough is not 
constant ; there are periods when it is entirely absent ; the disease then 
returns, perhaps with increased severity, and lingers indefinitely. 



298 



SPECIAL DIAGNOSIS. 



Chronic bronchitis consists in its milder form in what is often called 
"winter cough." It attacks especially persons past middle life, who 
have emphysema. It appears at the onset of cold weather, and lasts 
until the following summer. The cough is not severe, though some- 
times paroxysmal, and expectoration is scanty, non-purulent, and may 
be confined to the morniug. Dyspnoea is not marked unless there is 
considerable emphysema. Acute exacerbations occur from time to 
time, and the tendency of the disease is to become worse from year to 
year, and to be more continuous, even persisting throughout summer. 

In the dry catarrh, or catarrhe sec of Laennec, paroxysms of cough 
occur on the slightest provocation with the expectoratiou of small, hard 
pellets or without any expectoration. The patients are emphysematous. 

The diagnosis is made by noting the long duration of the disease with- 
out impairment of the general health, its relation to season, and the 
absence of physical signs of involvement of lung tissue. 

The physical signs of chronic bronchitis are those of bronchitis of the 
larger and middle-sized tubes. Large moist rales are more or less abun- 
dant, depending upon the degree of swelling of the mucous membrane 
and the quantity and fluidity of the secretion which is present. The 
respiratory murmur is roughened and less intense than normal. 

W. Fox says that in chronic bronchitis there is commonly hyper- 
resonance from coexisting emphysema, but under acute exacerbations the 
bases may be dull from congestion or oedema. Respiration is harsh, and 
in some cases of senile bronchitis expiration may be both prolonged and 
high pitched when other signs of dilatation of bronchial tubes are absent. 
The percussion note is clear. 

The sputa of the severe forms of chronic bronchitis are usually copious 
and muco-purulent, the latter predominating. They vary in color from 
yellowish-white to ashen, greenish, or black when the lungs are anthra- 
cotic or collapsed. 

The subjective symptoms of the patient consist, in ordinary cases, of a 
moderate amount of dyspnoea and tightness across the chest. At the 
onset of a fresh attack the symptoms may be those of acute bronchitis. 
The cough is paroxysmal, somewhat resembling that of whooping-cough, 
but without the characteristic whoop. It is usually severest on lying 
down and when risiug in the morning. 

The quantity and character of the sputa vary more than in acute 
bronchitis. Sometimes they are very copious, consisting of serum mixed 
with mucus, constituting bronchorrhcea. More commonly they are 
scanty, glairy, and tenacious. 

Chronic bronchitis may be the result of repeated acute attacks, or, 
rarely, may follow one. It is frequently found in association with gout, 
chronic heart disease, chronic endarteritis, and Bright's disease, emphy- 
sema, asthma, and chronic alcoholism. It may interchange with other 
gouty affections, as articular inflammation or eczema, being relieved 
when the other manifestations are more marked. It also accompanies 
tuberculosis of the lungs. Climate and season have a marked influence; 
the disease is worse in damp, cold climates, and in the winter months. 

Chronic bronchitis can be diagnosed from the cough of aneurism by 
the stridulous breathing due to paralysis of one-half of the vocal 



DISEASES OF THE 



LUNGS AND PLEURAE. 



299 



cords, and by the local signs of a tumor of the vessel, which are in 
marked contrast with those of bronchitis. Other tumors may cause 
cough by pressure, but may be detected if the possibility of their exist- 
ence is borne in mind. 

4. Plastic Bronchitis is a form of bronchitis, usually chronic, the 
characteristic feature of which is the expectoration of fibrinous casts, 
which, when unravelled under water, are found to be solid casts of the 
smaller bronchial tubes. The casts are often tree-like in shape, showing 
that a bronchial tube and its smaller subdivisions had been occluded by 
the casts. 

Persons of all ages are liable to it, but it affects males about twice as 
often as females. 

The subjective symptoms are cough aud dyspnoea ; haemoptysis occurs 
in about one-third of the cases (Biermer). 1 The cough occurs in parox- 
ysms, which are frequent and severe ; relief follows expectoration of the 
casts. 

Hemorrhage may appear as streaks of blood upon the casts, or be 
considerable, and follow their dislodgment. The casts themselves are 
usually ejected coated with mucus, so that they appear as solid masses 
of sputum ; their arrangement into cylinders may not be suspected until 
they are floated in water. The size of the cylinders varies from that of 
the little finger to that of a bodkin, but they do not often exceed the 
size of a goose-quill. The larger casts may be hollow, but the smaller 
ones are solid, and are arranged in layers. They are whitish or grayish 
in color, and firm in consistence, but become softer as the disease im- 
proves. Microscopically, the casts are nearly structureless, consisting of 
a fibrillated base, scattered with pus and mucous corpuscles, a few gland- 
cells, and occasionally blood-cells in the outer layers. Charcot-Leyden 
crystals and Curschmann's spirals are found. 

The acute form is rare, and out of ten cases accepted by Biermer, six 
proved fatal. The disease begins with fever, dyspnoea appears early, 
severe paroxysms of cough occur, sometimes hemorrhage. Death results 
from asphyxia. Grave symptoms are excessive dyspnoea with scanty ex- 
pectoration and drowsiness. Copious expectoration is a favorable sign. 

The duration of the chronic form is very variable, some cases lasting 
a number of years ; but it is not as a rule dangerous to life, nor does 
the general health suffer much. 

The Physical Signs. The casts obstruct the bronchial tubes. There 
is lessened amount of air entering the part, hence there is lessened fremi- 
tus and diminished respiratory murmur over the portions of lung sup- 
plied by the obstructed tubes. If collapse ensues there will be dulness 
on percussion ; if the casts are dislodged, the murmur becomes normal, 
or but slightly roughened. Over unaffected portions of the lung reson- 
ance is clear or exaggerated, and respiratory murmur unaltered. 

Puller says (quoted by Peacock : .Diseases of Chest) that the upper por- 
tions of the lungs are oftener affected than the lower portions. 

5. Fcetid or Putrid Bronchitis is the name applied to the condi- 
tion in which the sputa have a highly offensive odor and are copious 

1 Virchow : Handbuch der spec. Path. u. Ther., Bd. v. Abth. 1. 



300 



SPECIAL DIAGNOSIS. 



and semi-putrid. The odor is said by some to be due to microscopic 
sloughs, and by others to a special bacillus. 

Putrid bronchitis may accompany (1) dilatation of the bronchial tubes ; 
(2) chronic pneumonia ; (3) phthisis, or (4) empyema with a fistulous 
communication with a bronchus; or (5) it may occur independently. The 
subjective symptoms are cough, irregular fever, and occasional chills. 
The physical signs are those of chronic bronchitis, or of bronchitis and 
of the conditions with which it may be associated (q. v.). From gangrene 
it is diagnosticated by absence of physical signs of disintegration of lung 
tissue and by the absence from the sputum of fragments of lung tissue 
and elastic fibres. Nevertheless gangrene of the lung may be the final 
result of putrid bronchitis. 

The sputa of foetid bronchitis has an odor of gangrene or fseces. On 
standing they separate into three layers. The upper one consists of a 
greenish fluid or frothy layer ; the second is sero-albuminous, and the 
third a thick granular deposit in which are small masses the size of peas 
(Dittrich's plugs) and flakes consisting of granular detritus and contain- 
ing fat crystals and bacteria, the o'idium albicans, and crystals of leucin 
and tyrosin (Wilson Fox). (See Sputum.) 

Specific Bronchitis. 

In addition to the bronchitis that attends the infectious disorders 
mentioned above, three forms are seen of an infectious nature which are 
properly classified among the infectious disorders. It is proper to refer 
to them now, as bronchitis is usually the most pronounced local mani- 
festation. They are influenza, whooping-cough, and hay fever. The 
last only will be spoken of at present. 

Hay Fever. 

Hay fever is a specific catarrh of the respiratory passages, caused by 
the pollen of certain plants, principally the grasses. The attack begins 
with itching, burning, and lacrymation of the eyes, and pain in the 
brow or eyeballs. Subsequently there is itching or pricking of the 
nasal mucous membrane, frequent sneezing and an irritating watery 
discharge. The mucous membrane of the nose is red and swollen. A 
similar condition obtains in the throat when that is affected. If the 
disease attacks the bronchial mucous membrane a bronchitis is set up, 
which differs, if at all, from an ordinary bronchitis in being more per- 
sisteut and in being attended by greater dyspnoea, with asthmatic attacks. 

Bronchiectasis. 

Dilatation of the bronchi occurs secondarily to affections which tend 
to weaken the walls of the tubes and to lessen their elasticity. Hence 
it is found in chronic bronchitis with emphysema, in chronic phthisis, 
in catarrhal pneumonia in children, in chronic obstruction from external 
pressure or foreign bodies (see Obstructions). It also occurs when the 



DISEASES OF THE LUNGS AND PLEURA. 301 



lungs contract in fibroid pneumonia or pleural thickening. It occurs 
in two principal forms : the simple, in which the affected tubes are uni- 
formly dilated; and the saccular, in which larger or smaller pouches 
are formed. It is commoner in males than in females, and probably 
begins most frequently in adult or middle life. One lung only is 
affected in about one-half the cases, and when both lungs are affected 
(chronic bronchitis and emphysema) it is not often to the same degree. 

The subjective symptoms consist of cough, expectoration, and a vari- 
able amount of dyspnoea. Eventually there may be some loss of flesh 
and strength. 

The cough is usually paroxysmal. It may occur only in the morn- 
ing after the dilated tube fills. It may follow change in position. A 
paroxysm is followed by copious expectoration, sometimes amounting to 
a pint and a half in twenty-four hours. It is grayish-brown and 
muco-purulent, faintly or extremely foetid. The sputa contain mucus, 
pus, casts of the tubules, and various salts. Charcot-Leyden and fatty 
crystals, vibrios, leptothrix, and bacteria (Fox) can be found on micro- 
scopic examination. Elastic fibres are found only if the tubes are 
ulcerated. In a conical glass it separates in three layers — a frothy 
brown top, a thin mucoid layer in the middle, and below a granular 
layer. Hemorrhage is rare, but may occur even when tubercle is absent. 

Dyspnoea is not usually severe except when the dilatation is compli- 
cated by disease of the heart or lungs, or during an acute attack of 
bronchitis. 

The physical signs differ according to the extent of the dilatation 
and its kind. In simple dilatation there may be nothing different from 
the signs found in chronic bronchitis, except a tendency to more bron- 
chial respiration, with rales having a metallic quality. Percussion will 
vary according to the degree of alteration of the lung tissue surround- 
ing the affected bronchi and according to the extent of the dilatation 
and its nearness to the surface. In the simple forms the percussion 
note if altered is somewhat less resonant and higher in pitch, whereas 
in saccular dilatations favorably situated for percussion the note is tym- 
panitic if the pouch is empty. On auscultation in simple dilatation 
the breathing approaches the bronchial, and is accompanied by bron- 
chial rales. In saccular dilatation the sounds are practically those of a 
cavity, respiration varying from bronchial to amphoric. Vocal reso- 
nance and tactile fremitus are generally both increased, but the latter 
may be diminished. 

The diagnosis of simple dilatation from chronic bronchitis may be 
impossible, but copious and foetid expectoration indicates it. The diag- 
nosis of the saccular form from tuberculosis of the lung with cavity is 
difficult. Wilson Fox says the severer cases are usually associated 
with consolidation of the lung or with tubercle; but even without the 
presence of the latter they often present phthisical symptoms — retrac- 
tion of the chest, with the physical signs of excavation, pains in the 
side, haemoptysis, pyrexia, nocturnal perspiration, and diarrhoea — which 
may all coexist with only an induration of the lung and dilatation of 
the bronchi. The diagnosis must be made by noting the persistency of 
the physical signs, which change but very little and are not progressive 



302 



SPECIAL DIAGNOSIS. 



as are those of tuberculosis ; the protracted course of the disease ; the 
character of the sputum ; aud the comparatively slight impairmeut of 
the general health. 

Obstruction of the Bronchi. 

Obstruction may be produced by causes external to the tubes, or by 
internal causes, i. e., may be due to compression or to constriction. 

Compression may be by tumor, eularged glands, aneurism, hydatid 
cyst, mediastinal abscesses, aud long-coutinued pleural effusions and 
goitre. 

Constriction may be produced by swellings of the mucous membrane, 
by polypoid growths, or by growths forming in the lung and extending 
into the bronchi. Cicatrices may be produced by syphilis, tubercle, or 
by pleural thickenings. 

The symptoms depend upon the size of the tube and the degree of 
stenosis. When small areas are affected there may be no demonstrable 
physical signs, because the lung around the affected area becomes emphy- 
sematous. When large areas are affected, percussion often continues 
resonant, but its limits are said to be less influenced than in health by 
forced inspiration and expiration. The breath-sounds are Aveakened, 
and vocal resonance and fremitus are diminished in intensity and may 
be absent. Sibilant and sonorous rales may be heard at the site of the 
obstruction, and fremitus may be felt over the corresponding area. Dys- 
pnoea is proportioned to the stenosis and the size of the tube occluded. 

Asthma. 

Asthma is a chronic disease depending upon spasmodic narrowing of 
the bronchial tubes, and characterized by paroxysmal attacks of dys- 
pnoea, diminished respiratory movement of the chest, prolonged expi- 
ration attended by a w r heezing sound and sibilant rales, and ending 
abruptly with the expectoration of a tenacious mucus. The attack may 
be limited to a single night, or may be prolonged for days, with noctur- 
nal exacerbations. 

Premonitory symptoms are said to occur in about one-half the cases. 
These are for the most part nervous, such as headache, neuralgia, irri- 
tability of temper, vertigo, drowsiness. Hyde Salter found that there 
were premonitory symptoms in 111 out of 226 cases collected by him. 
In 63 they were nervous, in 8 there was profuse diuresis, and in 14 
they were connected with the digestive system. 

The attack itself usually begins during sleep, and often at a regular 
time. It may, however, begin during the day, and at a certain hour, 
independently of sleep. The onset is manifested by tightness across 
the chest and more or less difficulty in breathing. This dyspnoea in- 
creases rapidly and often reaches an extreme degree. The face becomes 
pale and anxious, and may be moistened with a cold perspiration ; the 
lips are dusky from deficient oxygenation of the blood. The patient 
feels smothered, and makes frantic efforts to get his breath, rushing to 
an open window, no matter how cold the weather, or if unable to leave 



DISEASES OF THE LUNGS AND PLEURJE. 303 



the bed, sitting up with the hands pressed upon the bed so as to give 
purchase to the accessory muscles of respiration. Notwithstanding great 
respiratory efforts are made, the chest moves but little, because the 
lungs are already distended to the extent of a full normal inspiration. 
The patient is uuable to expel the contained air owing to the spasm of 
the bronchial tubes. 

The frequency of respiration is diminished, sometimes to one-half 
the normal; the rhythm also is altered, inspiration being short and 
gasping, and followed without pause by expiration, which is much pro- 
longed and accompanied by a wheezing sound audible to bystanders. 

There is an increased amount of air in the thorax, and inability to 
remove it. The chest is enlarged — barrel-shaped — the movement is 
lessened and strikingly out of proportion to the efforts. The diaphragm 
is lowered. 

The physical signs are hyper-resonance on percussion ; on auscultation, 
faint, short inspiration, prolonged expiration, and sibilant and sonorous 
rales, more marked on expiration. 

The duration of an attack of asthma varies from half an hour to a 
day or two. In patients with chronic bronchitis it may be prolonged 
for a week or two, with remissions during the day. It may subside 
abruptly or by degrees. 

Subsidence of an attack is marked by expectoration, the sputa having 
special characteristics (see under Sputum). At first it is made up of 
rounded gelatinous masses which, when unfolded in water, are made up 
of spirals. Later, it becomes muco-purulent. 

No duration can be set down for the disease itself. It may be said 
that the earlier the age at which it begins the better the prospect of ulti- 
mate cure. If a cause can be discovered and its operation avoided the 
prospect of a cure is increased. 

The causative factors in asthma are various. About twice as many 
males as females are affected, and there is a marked hereditary tendency 
in some families. There is probably some special peculiarity in asth- 
matic patients, but just what it is has not been determined. It may 
reside in the lungs, and may be part of a general constutional irrita- 
bility (Salter). Bronchitis, emphysema, and heart disease act as causes, 
and so do syphilis, malarial poisoning, and chronic Bright's disease. 

Diseases with Increased Amount of Air. 
Emphysema. 

Emphysema consists in an " excessive, permanent, and unnatural dis- 
tention of the air-cells," or in " extravasation of air into the interlobular 
or subpleural cellular tissue." (Laennec.) 

Emphysema may be unilateral or bilateral. Local and unilateral 
forms are usually compensatory. Bilateral emphysema may be hyper- 
trophic or atrophic. 

It is more common in men than in women. Its symptoms are more 
common in childhood and after middle age. Two factors are essential 
in its causation. First, defective development of the elastic tissue of 



304 



SPECIAL DIAGNOSIS. 



the lungs. Second, increased intra-alveolar air-pressure. The latter is 
due to a number of causes. In childhood no doubt nasal and naso- 
pharyngeal obstructions are operative. In adults, occupations which 
necessitate continous and severe muscular effort, especially if coupled 
with forced expiration with closed glottis, act as causes. Such occupa- 
tions are blacksmi thing and playing upon wind instruments of music. 
Diseases which compel much cough iug or respiratory effort, such as 
chronic bronchitis and whooping-cough, act in the same manner. 
Chronic mitral valvular disease and the lessened elasticity of the lung 
tissue which come with advancing age both favor congestion of the 
lung, and thereby predispose to emphysema. The disease is hereditary. 
Several members of a family are affected. It occurs in mauy in child- 
hood, is in abeyance in adult life, and reappears in old age. 

Symptoms. The prominent symptoms in hypertrophic emphysema 
are dyspnoea, cyanosis, and cough, with expectoration from associated 
bronchitis. There is no fever. The dyspnoea is proportioned to the 
degree of emphysema present, and is aggravated by the coexistence of 
bronchitis, asthma, and eccentric hypertrophy of the right ventricle, 
which are very frequent complications in cases of long standing. 
When the degree of emphysema is only moderate, dyspnoea is not com- 
plained of except upon climbing or walking briskly, or after a hearty 
meal. But when the degree of emphysema is great, dyspnoea is con- 
stant ; it interferes with all exertion, frequently necessitates orthopnoea, 
and prevents continuous speech ; such patients speak in broken sen- 
tences or syllables. 

Cyanosis is marked. The livid lip is common in the asylums for 
old men. The extremities are also dusky, and the blueness is general 
in severe cases. This cyanosis, the round shoulders, and the drawn, 
chronically anxious expression, if I may so term it, make it easy to pick 
out the emphysematous subjects in a ward of chronic cases. 

The rate of respiration is not accelerated, and may be diminished in 
frequency. It is often accompanied by wheezing when chronic bron- 
chitis coexists. 

The cough varies greatly in frequency. It may be altogether absent, 
since its presence simply indicates an associated bronchitis. This bron- 
chitis may be present only in the winter for a long time. It may arise 
on changes of the weather. Finally it becomes chronic. The expec- 
toration is that of chronic bronchitis (q. v.) It is rarely stained with 
blood. 

The physical signs of emphysema depend upon its degree, and 
whether complicated with chronic bronchitis or not. Inspection : In 
well-marked cases the chest is barrel-shaped (see under Inspection). 
There is little movement of the chest in respiration, because the lung 
is already in a condition of full inspiration (expiratory dyspnoea). 
Vocal fremitus and resonance are usually diminished. Percussion : 
The percussion note is abnormally clear, and may even be tympanitic. 
Hyper-resonance is typical of the disease. When the distention is 
extreme the note may be woodeny. (See Fig. 36.) The lungs are 
enlarged. The heart dulness becomes obliterated by the overlapping 
lung. The upper margin of the liver falls one or two interspaces 



DISEASES OF THE LUNGS AND PLEURAE. 



305 



below the normal. The resonance extends higher above the clavicles 
than normal. 

On auscultation the inspiration is found to be distant and feebler 
than normal, while the expiration is prolonged, and may become three 
or four times the length of inspiration. Grazing or rubbing sounds 
have been described, and attributed to the friction of distended vesicles 
against the pleura. Other adventitious sounds are due to an associated 
bronchitis, pleurisy, or tuberculosis. But bronchitis is such a common 
accompaniment of emphysema that the rales of the former become 
almost symptomatic of the latter. Their character in emphysema does 
not differ from that in chronic bronchitis (q. v.) 

The Heart. The apex beat is absent. There is epigastric pulsation 
or systolic shock. The normal area of heart dulness is encroached 
upon by the distended lung, and the heart itself is pushed to the right, 
the apex beat frequently being at the xiphoid cartilage. If the emphy- 
sema attain a very high degree there may be no perceptible dulness 
except on very strong percussion over the cardiac region. The heart 
sounds appear feebler and more distant than normal. The right ven- 
tricle becomes dilated and hypertrophied, as the result of the pulmonary 
congestion produced by emphysema. The pulmonary second sound is 
accentuated. A tricuspid regurgitant murmur is heard. Venous con- 
gestions are common, in the later stages. Albuminuria is common. 
(Edema of the feet and limbs may occur, but general anasarca is 
rare. 

The general health suffers by loss of strength and capacity for physi- 
cal and mental work, rather than by loss of flesh. The patients are 
large chested, stoop-shouldered, aud short-breathed, and have an anxious 
expression of countenance. The face is of a dingy pale color, but 
becomes bluish on exertion. 

Diagnosis. This is based upon the history (heredity, occupation, 
long duration), the occurrence of dyspnoea and cyanosis, and of winter 
cough or chronic bronchitis, and the physical signs. 

Emphysema can be distinguished from pleural effusion and an aneur- 
ism, which may cause dyspnoea, by the universal hyper-resonance on 
percussion. Pleural effusion, which also causes bulging, is usually 
unilateral, and the percussion note over it is flat. There is diminution 
of areas of dulness about the heart and aorta in emphysema. 

Pneumothorax, which most resembles emphysema, develops suddenly, 
affects one side, and has a hollow, tympanitic note on percussion. The 
succussion splash, metallic tinkling, and coin test have no counterpart in 
emphysema ; moreover, the antecedent history and mode of development 
are different. 

Atrophic Emphysema is due to the degeneration of age. The 
lung is reduced in size. The diameters of the chest are lessened. The 
ribs are oblique. There is atrophy of the chest muscles. The patients 
have dyspnoea. There are other signs of senility. 

In interlobular emphysema the physical signs are the same as those of 
vesicular emphysema, but it develops suddenly and is liable to be 
followed by emphysema (intercellular) of the neck, which on palpation 
gives a peculiar crepitation. The friction sound and crackling which 

20 



306 



SPECIAL DIAGNOSIS. 



have been described as occasional adventitious sounds in vesicular 
emphysema are more commonly heard in the interlobular form. 

It is caused by rupture of the air-cells, and hence occurs in diseases 
in which a great strain is put upon them — especially, therefore, in 
whooping-cough, but also occasionally in pulmonary hemorrhage and 
pneumonia ; violent coughing and laughing, and great straining, as in 
child-labor, are capable of producing it. 

Diseases with Diminished Amount of Air. — The Consolidations. 

Congestion of the Lungs. 

Active Congestion. In active congestion there is increased amount 
of blood, which diminishes the air-space by encroachment and causes more 
or less consolidation. The signs of that physical condition are present — 
increased fremitus, impaired resonance or dulness, and bronchial breath- 
ing. The signs are observed on both sides, usually the bases. Dyspnoea, 
cough, and frothy, bloody expectoratiou attend the fluxion. Cases 
have not been reported in which bacteriological examination of the 
sputum was made. Of course the micrococcus lanceolatus is not found. 

If the above signs and symptoms develop suddenly — within twenty- 
four hours — a fluxion to the lung has in all probability taken place. 
If the patient is a subject of heart disease, or if he has been exposed to 
and has inhaled hot vapors or irritants, the probability of fluxion is in- 
creased. The occurrence of the symptom fever would point to pneu- 
monia as the cause of the objective and subjective symptoms. 

Passive Congestion. The physical condition that results is consol- 
idation. The bronchial mucous membrane is also congested. On account 
of the former there is slight dulness and feeble or bronchial breathing ; - 
on account of the latter, abundant rales. The affection is bilateral and 
usually confined to the bases, and of these, to the posterior portions. It 
is also secondary, a. Mechanical congestion occurs when the flow of 
blood to the heart is obstructed, as in organic valvular disease or in- 
sufficiency. Rarely, the pressure of tumors on the pulmonary veins 
acts in a similar manner, b. Hypostatic congestion occurs in fevers, as 
protracted typhoid, and in prolonged general exhaustion or adynamia. 
Ascites or other affections below the diaphragm, which lessen the re- 
spiratory excursion, cause this form. Dyspnoea, cough, and expectora- 
tion, with blood-stained sputum, are common. The sputum contains 
alveolar cells, but no micro-organisms. 

CEdema. The air-cells and alveolar walls are filled with serous ex- 
udation, as in oedema of the skin. It is frequently due to the weakness 
of the heart, which occurs at the end of long-continued diseases of an 
exhaustive nature, particularly if stress is thrown on the heart. It 
occurs, therefore, in the terminal stages of chronic Bright's disease, of 
organic heart disease, of the anaemias and cachexias. Both congestion 
and oedema occur in cerebral affections. 

Symptoms. They are those of congestion in a more aggravated 
degree. Dyspnoea, cough, and the expectoration of large quantities of 



DISEASES OF THE LUNGS AND PLEURiE. 



307 



a sero-mucoid fluid are seen. The diagnosis is based upon the results of 
physical examination aud the history of the presence or absence of the 
above causal factors. 

Pulmonary Embolism and Thrombosis. 

Pulmonary embolism cousists in plugging of the pulmonary artery or 
its branches by coagula formed in the right heart or in the veins. The 
symptoms depend upon the size of the occluded vessel and upon the 
nature of the embolus, i. <?., whether septic or not. If the artery itself 
is plugged, death takes place suddenly, or after a short interval, with 
symptoms of syncope or asphyxia. 

Symptoms. If a large branch is plugged, the first symptom is generally 
intense dyspnoea, which may amount to an agonizing craving for air. 
Pain in the chest, which may or may not be acute, is complained of and 
may be referred to the seat of the embolus. Cough is not a common 
symptom, and may be altogether absent. The breathing is considerably 
altered ; it is usually increased in frequency, and may be much hurried; 
it may or may not be shallow, and while the patient can take a deep 
inspiration, it does not give relief to his dyspnoea. At times it is irregu- 
lar and gasping. 

The face is pale, or may be cyanosed, and is apt to be bathed in 
perspiration. The veins are swollen and prominent. The heart's 
action is irregular and may be tumultuous. Exophthalmos has been 
observed. The temperature falls below normal, but a febrile rise may 
occur later. The intellect is unclouded. 

The physical signs are indefinite. The respiratory murmur is rough- 
ened and exaggerated in most, but not in all cases. Fox states that rales 
are very rarely heard. Collapse, oedema, and bronchitis are possible 
results. A systolic blowing murmur may be heard over the heart and 
pulmonary artery, and in protracted cases albuminuria and oedema may 
be met with. 

When the embolus is septic, a septic pneumonia or metastatic abscesses 
are probable results in cases not immediately fatal. 

When the emboli produce hemorrhagic infarcts, the symptoms are 
milder and consist principally in dyspnoea, pulmonary hemorrhage, and 
palpitation. The onset is sudden and accompanied by a fall in tempera- 
ture. The physical signs indicate consolidation, if the pneumonic or 
infarcted area is of moderate size. It may be discovered at the root of 
the lungs in the inter-scapular region. 

Hsemoptysis is a common symptom when the embolus has arisen in 
the heart. The amount of blood varies from a copious expectoration to 
the rusty sputum seen in pneumonia, but may persist for weeks. 
Pleurisy and pleural effusion are frequent complications ; chills occur 
sometimes, and pneumonia, with corresponding rise of temperature, may 
develop. 

The most important points in diagnosis are the sudden onset of the 
dyspnoea aud other pulmonary symptoms, and the detection of a con- 
dition which would give rise to emboli, such as puerperal fever or heart 
disease. 



308 



SPECIAL DIAGNOSIS. 



Pneumonia. 

Acute pneumonia, croupous or lobar pneumonia, is an infectious in- 
flammatory disease excited by the micrococcus lanceolatus (diplococcus 
pneumonias, pneumococcus) involving the vesicular structure of the 
lungs, and followed by choking of the alveoli with the products of in- 
flammation. 

Symptoms. Mode of Onset. The invasion of pneumonia is usually 
sudden, and is marked by a chill. The temperature rises rapidly and 
may reach 104° to 105° in the first twelve hours after the chill. With 
the fever, the patient complains of severe headache and pain in the side, 
and has a short, quick cough and sometimes vomiting. The pulse is 
accelerated moderately, and the respiration either is or soon becomes 
very frequent. The face is apt to be flushed, and there may be a cir- 
cumscribed red spot on the cheek. The skin is hot and dry. On physi- 
cal examination, within the first twenty-four hours, a small patch of 
consolidation is detected, which may subsequently extend over a large 
area. 

While this is the picture of an ordinary pneumonia in its early stage, 
all cases are by no means so clear. In some the course resembles that 
of a general fever in which the pulmonary disease is a local manifesta- 
tion. In such cases there may be prodromata, consisting of headache, 
general malaise, a slight bronchitis, and digestive disturbance. Then 
follows the chill. Central pneumonia. The fever may be high for 
several days before there is any discoverable consolidation of the lungs, 
and during this time cough be wholly or almost wholly absent. The 
respirations increase gradually in frequency, and finally a well-marked 
pneumonia can be made out. It is customary to account for these cases 
on the supposition that pneumonia developed in the interior of the lung 
and consolidation gradually extended to the surface. In some cases 
the patient presents no more definite symptoms for three or four days 
than high fever, intense headache, and moderately accelerated respiration. 

Later Stages. At the end of forty-eight hours, or at the most, of four 
days, the patient is found lying in bed in the dorsal position, or on the 
affected side. The face is flushed, the countenance anxious, the respira- 
tions hurried, the alas nasi play vigorously. The temperature varies little 
from the first day's rise ; the chest pain has been relieved, the short, 
dry cough is now attended by viscid expectoration. The respiration 
continues hurried, the pulse full and bounding. During this time the 
physical signs of consolidation continue and increase. 

After a period of five or ten days, the termination takes place by crisis. 
Previous to crisis, the pain in the chest lessens, the cough becomes 
looser, and the expectoration more free, but the other symptoms persist. 
In addition, in some cases, delirium occurs, the pulse softens and becomes 
dicrotic, the urine becomes albuminous. 

Respiratory Symptoms. Chest pain, cough, hurried respiration 
of a peculiar type, and expectoration are characteristic. The chest pain 
is sharp and stabbing or lancinating. It is increased by breathing. It 
is seated about the nipple or in the axillary region, at the angle of the 



DISEASES OF THE LUNGS AND PLEURJ. 



309 



scapula or complained of below the diaphragm. Its seat always indi- 
cates the side affected. Cough is short and dry, smothered and painful ; 
it soon becomes softer and painless as the expectoration becomes free. 
It may be absent in the feeble, in the aged, in alcoholic subjects, or in 
persons with brain disease, including insanity. 

A characteristic symptom of pneumonia is the increased frequency and 
the type of the respiration. The frequency in adults reaches 40, 50, or 
even 60 per minute, and in children 80 and 100 are not very uncommon. 

The pulse, on the contrary, does not increase in frequency in the 
same proportion ; hence, the normal ratio of respiration to pulse of 1 
to 4 ceases, and becomes 1 to 3 or 1 to 2. 

Inspiration is short, expiration quick and attended by an expiratory 
noise or grunt. The long pause may take place after inspiration in- 
stead of expiration. In children both are so short that unless the epi- 
gastrium is inspected it may be difficult to distinguish the two. 



Fig. 56. 





M 


E 


U E 




E 




E 








E 




E 


M E 




E 


M 


E 


M 


E 


M 




M 


E 




E 


M 


E 


105 
























































































































rl 






















































104- 






















A- 






























































































103- 






















A 














































f 


i 








i 






r 
























































i 


































102- 


















































































































iIOI- 










































































1 










































106- 














































































































































\ 
































99 
















































P 










































IK 










I 


1 






t 








d- 
'98 
































°\ 




A 










































































































































Pulse 


























































Dale 






O 












CI 


OS 






0 







Pneumonia. Sudden rise ; termination by crisis. Pseudo-crisis also seen. 



In ordinary cases which run a normal course, following the cough 
there is expectoration, which is at first viscid mucus, but gradually 
becomes reddish-brown from admixture of blood — the rusty sputum 
of pneumonia. This sputum is characteristic, almost pathognomonic. 
It is expelled with difficulty from the mouth, clinging to the lips, or 
if a male, to the mustache, when present. It cannot be removed from 
the spit-cup when turned over. It continues to be rusty, and as the 
crisis approaches becomes purulent and is discharged with ease. In 
typhoid pneumonia, it looks like prune-juice (see sputum). It contains 
blood, alveolar epithelium, the specific micrococcus, and later, pus and 
small fibrinous casts. 



310 



SPECIAL DIAGNOSIS. 



The Fever. The chill that precedes the fever is pronounced and 
always a warning to look for a pulmonic inflammation. If in children a 
convulsion is rarely absent in frank pneumonias. During its occurrence, 
the body temperature rises. The temperature in twelve hours reaches 
104° or 105.° It remains at this point, obeying the laws of diurnal 
variation. The hot dry skin, the parched lips, the dry tongue, the thirst, 
the anorexia, the hurried breathing, the occasional delirium, the loaded 
urine attest its presence. At the end of the third or more frequently 
the fifth, seventh, or ninth day, crisis takes place; the fall is abrupt and 
the normal or a subnormal temperature may be reached in from five to 
fifteen hours. Pseudo-crisis, as the accompanying chart indicates, may 
precede true crisis by twenty-four or forty-eight hours. The decline 
may take place by lysis, however. Protracted fever indicates delayed 
resolution or the occurrence of a complication. 

Cerebral Symptoms. In some cases, especially in children, the on- 
set of the disease may be marked by a convulsion. This is said to occur 
more frequently in apical pneumonias than in pneumonias of the base. 
Headache and delirium are so pronounced in some cases as to simulate 
meningitis. This is most likely to be the case in severe apical pneu- 
monias in children, and in double pneumonia, either in children or adults. 

Delirium may occur during the height of the fever, and occasionally 
is maniacal. Nocturnal delirium may be a constant symptom in 
very grave cases. In drunkards it may simulate delirium tremens, 
and in them and the aged may be pronounced without much fever. In 
the later stages of grave or fatal cases, a low form of delirium, with a 
tendency to coma, is common. 

The Heart and Pulse. The latter is small at the time of the 
chill, but becomes full and bounding during the fever; later it may be- 
come dicrotic. The pulse-respiration ratio has been referred to. The 
pulse varies in frequency and in character with the type of the disease. 
In healthy adults it is rarely over 110. In the debilitated it may be very 
frequent, small, and feeble ; in the aged, frequent and dicrotic. Ex- 
tensive consolidations lessen the amount of blood in the general circula- 
tion, cause rapid action of the heart and a small pulse, and favor death 
with the heart in asystole. 

The heart sounds are clear. A murmur low in pitch is often heard in 
the mitral and pulmonary areas. The left ventricle acts forcibly. The 
pulmonary second sound is accentuated. If dilatation and failure of the 
right heart take place, the area of dulness may extend beyond the right 
edge of the sternum, an epigastric impulse be noted, turgescence of 
the veins in the neck become marked, but above all, the previously 
accentuated pulmonic second become weak or disappear. 

Gastro-intestinal Symptoms. Vomiting frequently occurs in 
children at the onset, and both in them and in adults may persist and 
mask pulmonary symptoms. The appetite is lost. The tongue is 
furred. It may become dry and brown. The bowels are constipated 
except when complications occur. The spleen is enlarged. 

Cutaneous Symptoms. Herpes on the lips, the nose or the geni- 
tals is of common occurrence. Sweating occurs with the crisis, or if 
heart failure is imminent. 



DISEASES OF THE LUNGS AND PLEURA. 311 



The Urine. The urine is scanty and high-colored, and may con- 
tain a small amount of albumin. In some cases the chlorides are found 
to be absent. This is determined by acidulating the urine with a drop 
or two of nitric acid, and then adding one or two drops of a ten per 
cent, solution of silver nitrate. If chlorides are present a heavy white 
cloud of chloride of silver is thrown down. The chlorides are not in- 
variably absent, or even diminished in pneumonia, hence their reappear- 
ance, which is said to indicate beginning convalescence, loses its value as 
a prognostic sign. 

Physical Signs. Consolidation. Diminution in the amount of 
air, increase of solid contents. On inspection, diminished movement. If 
extensive consolidation, enlargement of the affected side. On palpation, 
inspection confirmed and increased vocal fremitus discovered. Both are 
more marked at the height of consolidation. Percussion. In first stage, 
impaired resonance or Skodaic resonance. In stage of hepatization, dul- 
ness or flatness, but without any wooden quality or marked resistance. 

Auscultation. In the early stage, that of congestion, the respiratory 
murmur is suppressed and crepitaut rales are heard at the end of in- 
spiration. On full inspiration or after a cough a broncho- vesicular 
respiration is brought out. When consolidation has taken place the 
respiratory murmur is bronchial. Rales, if present, are moist sub- 
crepitant rales from associated bronchitis, or a few crepitant rales may 
still persist, and a friction sound be heard. 

When resolution sets in, the crepitant rale reappears, quickly followed 
by moist subcrepitaut rales heard both on inspiration and expiration, 
while dulness gradually yields to impaired resonance. The respiration 
loses its bronchial character and again acquires a vesicular element be- 
fore becoming completely normal. It may be a week or two, or many 
months, even in uncomplicated cases, before the percussion note becomes 
perfectly clear and rales wholly disappear. 

Duration and Course. The duration of the disease is from one to 
two weeks. It may subside by crisis on the third, fifth, seventh, or ninth 
day, or gradually by lysis. Crisis is marked by a critical sweat, a 
copious discharge of limpid urine, or sometimes by a few loose move- 
ments of the bowels, accompanying a fall of temperature to or below 
normal. 

Instead of clearing up, the pneumonia may progress to suppuration, 
abscess, or gangrene. These conditions can be made out by the charac- 
ter and range of temperature, the general condition of the patient, the 
sputum, and the physical signs. Termination in abscess or gangrene is 
rare. 

In cases proceeding to a fatal issue the strength fails, respiration 
becomes more labored, and expectoration increasingly difficult. The 
number of respirations frequently diminishes, but the pulse continues 
frequent and often becomes small and irregular. Physical examination 
shows diffuse bronchitis with oedema. The heart's action is irregular 
and rapid. The sounds are weak and feeble; the first becomes short and 
snappy like the second, and later both are weak or indistinct. Death 
may occur abruptly from convulsion, or more frequently from the devel- 
opment of asphyxia, due to oedema of the lungs, which in turn set in 



312 



SPECIAL DIAGNOSIS. 



on account of weakness of the heart or the development of heart-clot 
from cardiac asystole. 

Varieties. Migratory pneumonia. Sometimes, with the reappear- 
ance of abundant rales and increased expectoration, the fever continues 
high, the patient is disinclined to take food, has a dry, brown tongue, 
and is often delirious. In such cases the pneumonia is probably extend- 
ing in the lung already involved, or has attacked the other lung. 

Typhoid pneumonia is an unfortunate name for an adynamic form of 
the disease with typhoid symptoms. If it arises in the course of, or 
complicates, low fevers, it is usually of the typhoid type ; but it occurs 
also in those much exhausted, in depraved health, or exposed to unhy- 
gienic surroundings. It is found also in cases of septicaemia, in Bright's 
disease, in drunkards, and in the negroes in the southern part of the 
United States. 

The characteristic features of this form of pneumonia are the great 
physical prostration and the weak heart-action. The fever is high, the 
respiration and pulse frequent, and delirium and vomiting are more fre- 
quent than in the ordinary form. The skin sometimes has a dusky hue; 
the tongue is heavily coated, or may be dry and brown, and sordes col- 
lect on the teeth. The sputa may be rusty, and sometimes pure blood 
is expectorated. The disease may prove fatal rapidly, or may linger 
for a long time, the patient only gradually coming out of a low typhoid 
state. It is always dangerous. 

Bilious pneumonia is the name given to a type of pneumonia occur- 
ring in persons laboring at the same time under malarial poisoning. 
The initial chill lasts longer, and the pain in the side, from coincident 
pleurisy, is more marked than in ordinary pneumonia. The fever is 
more remittent, and jaundice and vomiting are present. 

Diagnosis. The diagnosis is based upon the aggregation of special 
symptoms. The mode of onset, the chill, the course of the fever, the pain 
in the chest, the cough, the peculiar expectoration, the dyspnoea, the 
abnormal pulse-respiration ratio, the peculiar character of breathing, 
and the physical signs are common symptoms. It must be remembered 
that in children, in the aged, in drunkards, in cases of chronic disease, 
the type is deviated from. In drunkards cerebral symptoms are more 
marked. In children the cerebral symptoms are more prominent, the 
expectoration often absent. In the aged, the cough, the expectoration, 
and the fever are not pronounced ; the former may be absent ; the 
onset is insidious. The same onset and course occur in wasting dis- 
eases, as cancer, phthisis, Bright's disease, diabetes, and organic heart 
disease. It must be remembered that in this class of cases a small 
patch of pneumonia, difficult to determine on physical examination, 
may be attended by the gravest general symptoms. In all of the above 
cases, if there is fever without cause, although no pulmonary symp- 
toms are present, the lungs must be examined repeatedly. In many of 
such cases the physical signs are obscured because 'respiratory action 
is enfeebled by the primary condition. 

Pneumonia must be distinguished from other acute inflammatory 
affections of the lung and pleura and from acute tuberculo-pneumonic 
phthisis. The evidence for each is considered in the respective sections. 



DISEASES OF THE LUNGS AND PL EUR . 



313 



To distinguish pneumonia from pleurisy with effusion the aspirator 
must be used. 

Bacteriological Diagnosis. Staining and microscopical examination 
of the sputum reveals the characteristic micro-organism. Care must 
be taken to secure sputum from the lung. By inoculation of rabbits 
with the sputum the disease is readily reproduced. The organism is not 
readily found in the blood. 

Complications. The complications which occur in the course of 
the disease and modify the clinical picture and obscure the diagnosis 
are : pleurisy with serous or purulent exudation, pericarditis, endo- 
carditis, meningitis, and jaundice. 

Broncho -pneumonia, or Catarrhal Pneumonia, is a pneu- 
monia occurring secondarily to bronchitis, and is characterized by the 
development of areas of consolidation in both lungs and the persistence 
of a bronchitis of the middle-sized or smaller tubes. In proportion as 
the areas of consolidation are large, the symptoms and physical signs 
approach those of lobar pneumonia. It is more common in children 
and in debilitated persons. It is the chief form in infants. I. It is 
frequently secondary to measles, diphtheria, scarlet fever, and pertussis. 
2. As aspiration-pneumonia, it occurs when food, septic particles, blood 
or tissue enter the lungs during the loss of sensibility of the larynx in 
apoplectic, ursemic or other forms of coma, and in operations about 
the upper air-passages and mouth. It is a fatal complication of trache- 
otomy. 3. It is frequently of tuberculous origin. 

Catarrhal pneumonia, except the aspiration form, develops gradually, 
and it may not be easy always to mark the point at which the bron- 
chitis which precedes merges into pneumonia ; but as a rule there is 
more or less chilliness (rarely a decided chill), and an access of fever. 
There is usually greater prostration in proportion to the amount of 
pneumonia present than in the lobar form. The pulse is more frequent 
and more likely to be feeble. Cough and expectoration are marked 
symptoms. The sputum is tenacious and glairy, not rusty. Dyspnoea 
is more extreme than in lobar pneumonia. The respirations are exces- 
sively rapid — sixty to eighty per minute; cyanosis rapidly ensues. The 
finger-tips become blue, the face dusky. The fever does not rise as 
high as in the lobar form. At first the skin is hot and dry ; later it 
becomes cool and clammy, and in the tuberculous form sweats are com- 
mon. The duration of the disease is usually much longer than in lobar 
pneumonia. 

The physical signs are those of bronchitis, with here and there larger 
or smaller areas of consolidation, over which the rales are finer and 
closer set; the percussion note is dull, and the respiratory murmur 
bronchial or broncho-vesicular. Areas of collapse and portions more 
or less oedematous combine to make up the complex of physical signs. 
While both lungs are affected they are not usually affected to the same 
degree. It is said that the apices are more prone to involvement in 
this than in the lobar form ; and some writers (Osier) look upon it as 
a form of phthisis. 

In the common form seen in infants the symptoms of asphyxia set 
in at variable periods in the course of the disease. General cyanosis 



314 



SPECIAL DIAGNOSIS. 



supervenes. Stupor sets in, the hurried respirations grow shorter aud 
more gasping, the pulse becomes excessively rapid and feeble, the 
extremities cool and clammy ; with the stupor the cough lessens and 
the breathing becomes more shallow. The lungs fill up with fluid 
mucus, and the child drowns in its own secretions, or cardiac paralysis 
sets in after dilatation of the right heart. 

Diagnosis. The affection is distinguished (1) by its pathological 
antecedents aud causal relations; (2) its gradual onset; (3) its distribu- 
tion in both lungs; (4) the preponderance of physical signs of bronchitis 
over those of consolidation; (5) the extreme dyspnoea and cyanosis with 
a lower temperature than in lobar pneumonia ; (6) the onset of carbon 
dioxide poisoning; (7) the long duration and gradual decline. The 
tuberculous form is distinguished by (1) the history of exposure to 
infection or of a focus of infection in the body, glands, or joints ; (2) the 
longer course ; (3) delayed asphyxia ; (4) rapid emaciation ; (5) profuse 
sweats ; (6) physical signs of consolidation and subsequently of cavity 
at the apex ; and (7) absolutely by tubercle bacilli in the expectoration 
coughed up or vomited. I have seen a child aged fifteen months, of a 
tuberculous mother, completely recover. The tuberculous form is 
common in colored infants. 

Chronic Interstitial Pneumonia. 

Cirrhosis, fibroid phthisis, and chronic interstitial pneumonia are 
names given to a condition of chronic induration of the lung caused by 
an interstitial overgrowth of fibrous tissue. Obliteration of the air- 
vesicles and contraction of the lung result from the overgrowth. The 
bronchi are frequently dilated, and cavities and gangrene may occur. 
The disease is rare except as the result of tubercle, but it may follow 
pneumonia and pleurisy, and it is said to be caused by the inhalation of 
fine particles of steel or cotton. Pneumonokoniosis is the term, first 
employed by Zenker, for the chronic interstitial pneumonia from the 
inhalation of dust. 

Physical Signs. Inspection. The disease is unilateral. The chest 
wall is retracted. The ribs are drawn together so that the interspaces 
are obliterated. The shoulder is drawn over the sunken thorax. The 
spinal column is curved. The heart is displaced. It is drawn toward 
the affected side. If the right lung is the seat of disease an impulse is 
seen to the right of the sternum ; if the left, the prsecordial area of impulse 
is increased and extends upward. There is no expansion whatsoever 
(immobility) of the affected apex or base. The healthy lung is the seat of 
compensatory emphysema. 

Palpation. Inspection is confirmed. Fremitus is increased, espe- 
cially at the apex. At the base pleural thickening lessens fremitus. 

Percussion. The physical signs show increased density of lung 
tissue, with dulness on percussion, or, over a dilated bronchus, a tym- 
panitic or amphoric note. 

Auscultation. The respiratory murmur is bronchial, or over a dilated 
bronchus has a hollow sound. At the base breath-sounds are feeble, 
distant or absent. Rales are also heard. 



DISEASES OF THE LUNGS AND PLEURJ. 



315 



The disease runs a very chronic course attended by cough, and 
muco-purulent, sero-purulent, and sometimes bloody expectoration, 
even hemorrhage ; but there is no fever and not much loss of flesh. 
Dyspnoea occurs on ascending heights only. Dilatation of the right 
heart is liable to ensue, with cardiac murmurs and increased lateral dul- 
ness and increase of dyspnoea. Death is hastened by the disease, and 
is often brought about by an acute pneumonia. 

In pneumonokoniosis (also known as anthracosis, coal miner's dis- 
ease ; siderosis, from metallic dust ; chalicosis, from mineral dust, as in 
stonecutter's phthisis), there is a history of exposure to the irritating 
particles for a considerable period, during which time cough develops, 
gradually increases, and the general health fails. Emphysema simulta- 
neously arises, causing dyspnoea. The patients wheeze, cough in par- 
oxysms, and expectorate sputum which contains the dust particles. In 
anthracosis it is black. On microscopical examination, the special dust 
particles are often found. The symptoms of emphysema and chronic 
bronchitis become paramount. Tubercular infection may take place 
late in the disease. 

Pulmonary Tuberculosis. 

For convenience of diagnosis the specific inflammation of the lungs 
caused by the bacillus tuberculosis will be considered in this section. If 
a strict serological classification were followed it should be considered 
among the infectious diseases. 

Clinically, we see tuberculosis in the lungs made manifest in one of 
the forms of acute pneumonic phthisis, acute miliary tuberculosis, and 
chronic ulcerative phthisis. 

Definition. Tuberculosis of the lungs, pulmonary phthisis, and 
consumption, are names applied to an infectious and mildly contagious 
disease of the lungs, caused by the tubercle bacillus, appearing in an 
acute and chronic form, and characterized by cough, fever, sweats, more 
or less rapid emaciation, purulent expectoration containing elastic tibres 
and tubercle bacilli, and by peculiar physical signs. 

Acute Pulmonary Tuberculosis, Acute Phthisis, Acute 
Pneumonic Phthisis, or Galloping Consumption, may be primary, 
or be secondary to a localized area in the lung causing rapid infection, 
or to tubercular pleurisy, tubercular peritonitis, or tuberculosis of 
some other organ. Its onset is usually marked by cough, fever with 
or without chills, dyspnoea, and sometimes haemoptysis. The fever 
rises to 103° or 104°, and is of a continued type, or rapidly assumes 
a hectic type, accompanied by restlessness and exhausting night-sweats, 
anorexia, and rapid emaciation. Prostration of strength is extreme, 
but the mind is at first clear and the spirits cheerful. Cough 
increases, the expectoration, at first mucoid and scanty, but often tinged 
with blood, becomes more copious and muco-purulent. The bowels may 
be loose or constipated. 

When death takes place without more decided pulmonary symptoms, 
the tuberculosis has been secondary to tuberculosis elsewhere, or death 
is the result of a general miliary tuberculosis. 



316 



SPECIAL DIAGNOSIS. 



When the acute pulmonary tuberculosis is primary the character of 
the disease is soon made clear by the early development of consolidation 
of the lungs, usually of an apex first, rapidly followed by softening 
and the formation of cavities. The sputum becomes muco-purulent, 
then purulent, is frequently streaked with blood, and pure blood is 
often coughed up. The sputum contains yellow elastic tissue and 
abundant tubercle bacilli. 

The patient often presents a cachectic appearance ; emaciation has 
been very rapid, and has reached an extreme degree; there is frequently 
a red flush about the cheek-bones, which, with the bright eves, contrasts 
strongly with the hollow cheeks and temples, and the white wasted 
hands and clubbed fingers w T ith bluish nails. 

The patient's mental attitude is usually peculiarly and characteristi- 
cally hopeful. He expresses himself as better each day, though occa- 
sionally subject to despondency, and is sure that if he could only gain 
a little strength he would soon be well. 

Sometimes, especially in children, the disease is latent. The patient 
suffers from weariness, the cheeks flush easily, the pulse is readily dis- 
turbed, there are nocturnal fever and occasional sweatings. Emaciation 
proceeds very gradually, and a long time may elapse before any disease 
is demonstrable. 

In a few cases the cerebral symptoms are so pronounced as to mask 
the pulmonary, and in other cases there is actual coincident involve- 
ment of the cerebral meninges. 

The physical signs are those of consolidation, often with conjoint 
pleurisy. The apex is usually first invaded. There is diminished 
movement, increased fremitus, and dulness on percussion. At first the 
breathing is broncho- vesicular. It rapidly becomes bronchial. At 
first small moist rales are detected. Later they become large and gur- 
gling. A pleural friction may be heard. It may first be heard above 
the spine of the scapula behind, above the clavicle in front, or high up 
in the axilla. The upper lobe of the right lung may be affected first, or 
the anterior portion of the middle lobe. The physical signs may be 
observed first in the axillary region of either side. The consolidation 
extends to the remainder of the lung, being preceded by physical signs in- 
dicating gradual encroachment upon the air-containing structure. The 
respiratory murmur is harsh, but soon becomes broncho-vesicular and 
then bronchial. As consolidation progresses in the middle and lower por- 
tions of the affected lung, signs of cavity or multiple cavities appear in the 
upper. (The whole of a lobe may be the seat of small cavities filled 
with muco-purulent or purulent fluid.) Cavernous breathing and pec- 
toriloquy, or the bronchial sniff of consolidation, becomes more pro- 
nounced. The dull note of consolidation is relieved by a dull tympan- 
itic or full tympanitic note. Now moist rales of all degrees are heard. 
Above they are gurgling; below, small and large moist rales. If the 
progress is not too rapid throughout the lung first affected, signs of 
invasion are found in the remaining lung, usually at a point correspond- 
ing to the primary focus in the original lung. The apex, therefore, is 
first invaded in most cases. Infection of the second may begin earlier 
than the signs in the first lung would lead one to anticipate. The rapid 



DISEASES OF THE LUNGS AND PLEURA. 



317 



invasion of one lung compels compensatory emphysema of the other. 
The increased movement, with harsh or puerile breathing, without 
change in fremitus or in pitch and tone on percussion, mask any small 
consolidations. 

The expectoration becomes more purulent as the disease progresses, 
and may be blood-tinged. It is copious and possesses some feet or. It 
is found to swarm with bacilli and to contain yellow elastic tissue. 
Hemorrhage may take place. The general symptoms become more 
alarming. The fever becomes of a hectic type. The patient rapidly 
emaciates. Cyanosis is shown in the dusky countenance and blue 
finger-tips. The exhaustion becomes extreme. Pallor, with flushed 
cheeks and an anxious countenance, is seen. The sweats are profuse. 
The appetite is lost. Diarrhoea may set in. Remissions may take 
place, even in acute cases; for a time the fever and more aggravated 
pulmonary symptoms are in abeyance. The typhoid state ensues in 
some cases. Death takes place from exhaustion and heart-clot or from 
meningeal tuberculosis. The duration is from two to six weeks. 

Diagnosis. In the earliest stages, before the invasion of new terri- 
tory is pronounced, the cases are involved in doubt. It may be con- 
founded with pneumonia until the sputum is secured or bacilli found. 

In pneumonia we have the pronounced rigor, the rapid rise of tem- 
perature, the altered pulse-respiration ratio, the hot dry skin, the sticky 
viscid sputum, containing the pneumococcus, the peculiar changes in 
the urine, the occurrence of herpes, the termination by crisis, to point 
to the nature of the process. The sputum is more purulent in acute 
pneumonic phthisis. Then cavity formation does not take place, or at 
least rarely. Emaciation is not marked, sweating does not occur corre- 
sponding to the repeated drenchings we see in pneumonic phthisis; 
anaemia is not so pronounced. In pneumonia the fever is of a con- 
tinued type ; in phthisis it is often intermittent or remittent. Finally, 
the history of exposure to infection by the disease, the primary occur- 
rence of tuberculosis elsewhere, the secondary occurrence of tuber- 
culosis in other organs after the lung invasion, the longer duration — 
aid in determining the true affection. Inoculation of animals may be 
resorted to in doubtful cases. 

Acute Miliary Tuberculosis is attended by high fever, rapid 
emaciation, hurried breathing, rapid pulse, duskiness of face and 
extremities, more or less stupor, delirium, and the development of the 
typhoid state, with prostration and the occurrence of profuse sweats. 
Intestinal symptoms, as flatulency and distention, may be pronounced, 
and diarrhoea a prominent feature. Physical signs are negative or are 
those of bronchitis. There is resonance or hyper-resonance on percus- 
sion. The latter is not uncommon. The onset is abrupt or may follow 
a period of malaise. In some instances the tuberculous process is 
more advanced in some situations than in others, giving rise to special 
local symptoms. Thus, recently a patient was admitted to the Presby- 
terian Hospital with stupor and moderate delirium. He had fever, 
rapid pulse and breathing, and a peculiar dry, harsh skin. There was 
albuminuria, casts and blood in the urine, and it was thought he had 
uraemia. The temperature range was irregularly intermittent. The 



318 



SPECIAL DIAGNOSIS. 



diagnosis was established later because of the development of undoubted 
secondary tuberculosis in other organs. At the autopsy general tuber- 
culosis was found, with primary tuberculous ulceration in the bladder, 
the ureters and renal pelves. 

Diagnosis. Hurried breathing and cyanosis are distinctive features, 
out of all proportion to the physical signs, and, on this account, of 
diagnostic significance. It must be distinguished from typhoid fever, 
septicaemia or pyaemia, and malignant endocarditis. From the former 
it is distinguished by the difference in character and relations of the 
general and special symptoms to the period of the disease. In typhoid 
fever the evolution of the disease, rather than its symptoms, is char- 
acteristic. The headache of the first week, finally disappearing, is 
noteworthy. The special range of temperature, the onset, the fastigium, 
and the defervesence at definite periods in the evolution of the disease, are 
of diagnostic value. Cyanosis is more constant and marked in tuber- 
culosis. The skin and capillaries have more tone in typhoid fever 
than in tuberculosis, at least in the first two weeks. Hyperaernia fol- 
lows irritation in typhoid ; pallor, with duskiness, in tuberculosis. The 
eruption, with its specific mode of development, belongs to typhoid 
fever alone. The stools, the enlarged spleen, the vascular tone are sug- 
gestive. Bacteriological examination may be of service. The occurrence 
of intestinal hemorrhage, pointing as it does to typhoid fever, is a welcome 
sign in cases in which the diagnosis is obscure. I have never seen it in 
tuberculosis. In typhoid fever the reflexes (knee-jerk) are never absent; 
in tuberculosis, if the meninges are involved, they are variable, present 
one day, absent the next. The diazo reaction in typhoid is of service, 
although it also occurs in tuberculosis. In the latter, unlike typhoid, 
it does not come on until later than the fifth day. It disappears at a 
proper time in the involution of typhoid ; it continues in tuberculosis. 

The distinction of tuberculosis from septicaemia or pyaemia and malig- 
nant endocarditis 'is often difficult. Search must be made for local areas 
of septic or pyaemic infection. The ears, the bones, the veins, the heart, 
the pelvic organs in females, the rectum, the genito-urinary tract — must 
be carefully examined. Hemorrhagic infarcts, or metastatic abscesses, 
may be found which point to the original conditions. The eye-ground 
may show hemorrhages. The skin aud mucous membranes may exhibit 
minute capillary hemorrhages or infarcts. They are of the size of a 
pin-head, do not disappear on pressure, and are not elevated. The 
spleen is more likely to be enlarged in the septic affections. The 
respirations are not so rapid as in tuberculosis. Cyanosis is a distinc- 
tive feature of tuberculosis. The physical signs of endocarditis may 
be determined, aud subsequently embolism or thrombosis prove the 
nature of the process. 

Chronic Tuberculosis; Chronic Ulcerative Phthisis. 
Chronic tuberculosis or phthisis is much more common than acute 
tuberculosis, from which it is distinguished by its slow progress and by 
periods of remission during which the disease may be arrested tempo- 
rarily or permanently. 

It may begin in a variety of ways. The most common mode of 
origin is in an ordinary bronchitis with which pleurisy is occasionally 



DISEASES OF THE LUNGS AND PLEURA. 



319 



associated. Previous to this the patient may have been in good health, 
but generally the health has been impaired for some time. The bron- 
chitis may be simple or be part of influenza, measles, whooping-cough, 
or some other specific disease. 

The bronchitis usually proves obstinate, and by and by there is 
found at the apex of the lung a small area over which on percussion 
there is increased resistance, with slight impairment of resonance, as 
compared with the other side; the respiratory murmur is broncho- 
vesicular, sometimes jerky in rhythm, and the vocal resonance and 
fremitus slightly increased or uualtered. Such physical signs are met 
with more frequently at the right apex than at the left, and oftener in 
the supra-scapular fossa than anteriorly. The next most frequent seat 
is probably between the clavicle and second rib anteriorly. 

The patient will be found to have lost strength, and usually some 
weight. There is often a slight evening rise of temperature, and occa- 
sionally nocturnal perspirations. The appetite is impaired, and an- 
orexia may exist. Cough is rarely absent, especially during the night 
or on waking in the morning; it may, however, be so slight as appar- 
ently to have escaped the notice of the patient. When characteristic it 
is dry and hacking. Expectoration is scanty and mucoid, but occa- 
sionally it may be tinged with blood. It should be remembered that 
children and old persons sometimes do not expectorate, and that, as a 
rule, women are more inclined to suppress expectoration than men. No 
tubercle bacilli may be found in the sputum after repeated examination, 
but if examinations are continued they will appear sooner or later. 

Instead of developing after a bronchitis, as we have just described, 
it may set in suddenly under the guise of a pneumonia, more fre- 
quently of the catarrhal form. The symptoms and physical signs do 
not differ esseutially from those of pneumonia except that the expecto- 
ration is more likely to be profuse, muco-purulent and blood-streaked, 
and bacilli are found in it ; the fever is more hectic in type, and night- 
sweats are common. The consolidation is found at the apex. After 
the patient convalesces from such an attack he continues weak, does 
not gain flesh readily, still has a cough with expectoration, evening 
fever with occasional night-sweats, and an area of consolidation usually 
at an apex of the lung. Over this area, in addition to the usual signs 
of consolidation (bronchial or feeble breathing, dulness, etc.), moist or 
dry subcrepitant rales are heard. 

In some cases, fever, emaciation, and weakness progress for some 
time before pulmonary symptoms arise. 

In still other cases the invasion of the disease is by sudden haemo- 
ptysis, which is oftener copious than not. Several such hemorrhages 
may occur in rapid succession, or there may be only one. Moreover, 
its disappearance may not be followed, or least not immediately, by any 
further pulmonary symptoms or physical signs; more commonly, how- 
ever, it is followed by a fever, cough, expectoration, and physical signs 
of incipient consolidation, usually at the apex. 

In still other, but rarer cases, the pulmonary disease is latent, being 
masked by gastric or peritoneal symptoms, or by a general anaemia. 

By whatever path invasion comes the physician should be on the 



320 



SPECIAL DIAGNOSIS. 



lookout for it, especially in a young adult predisposed by heredity or 
enviroument to tuberculosis. The recognition of the disease in its 
early stage requires the greatest skill, which in turn is recompensed 
with the highest reward, since the disease is then curable. 

The further progress of a case of tuberculosis of the lungs, after 
consolidation has once become manifest, is very variable. It may be 
arrested at this point permanently, cure resulting from cicatrization. 
More frequently there is temporary arrest of the process ; fever lessens 
or ceases entirely, the pulse resumes its normal rate, appetite improves, 
and there is a gain in flesh and strength. Cough and expectoration 
are more likely to persist than the other symptoms, but with the other 
improvement they lessen in frequency and copiousness. There are 
fewer rales, but the signs of consolidation are still present, though there 
is no further extension of the process. Often, after a cavity has been 
found, the disease is arrested, does not progress, or progresses very 
slowly. 

After a longer or shorter time, as the result of re-infection from the 
old focus excited by acute bronchitis or by some depressing influence, the 
tuberculosis is re- lighted, so to speak, and runs much the same course, 
the lung being left more diseased and the general health worse after 
every such attack. Nevertheless there may be long intervals between 
such attacks, the patient in the meantime continuing in fair health. 
Thus the disease may linger or recur for years, the patient not ill 
enough to be confined to the house, and not well enough to stand hard 
work or great exposure. Slowly, by ulceration and suppuration, the 
lung tissue is wasted and cavities formed. Before there are large 
cavities at an apex the base of the same lung becomes consolidated by 
the production of tubercular material, and before one lung is exten- 
sively diseased the apex of the opposite lung is attacked, the process 
beiug repeated in it if the patient live long enough. Instead of re- 
infection from an old focus, new infection may take place, giving rise to 
the old train of symptoms, or setting up more acute disease. During 
this time the patient is liable to an attack of acute pneumonia, 
pleurisy, bronchitis, or general miliary tuberculosis. He is also liable 
to sudden death by hemorrhage. In a number of cases the intestines 
and peritoneum become affected, and abdominal pain and diarrhoea 
become superadded as symptoms. 

The progress of the patient is downward. The later stages are 
marked by increasing cough and dyspnoea, which are very distressing 
and prevent sleep. Expectoration is more copious, is purulent, and 
is raised with increasing difficulty. 

The appetite is poor and capricious, or anorexia is complete. The 
heart becomes more and more teeble, the fever is hectic and accompanied 
by exhausting night-sweats, the feet and limbs swell, and acute cramp- 
like pains are felt in the legs, probably caused by thrombosis of the 
veins 

Emaciation is extreme, scarcely anything but skin and bone being 
left. Death occurs from perforation of an intestinal or gastric ulcer, 
from hemorrhage, or more commonly by exhaustion and asphyxia from 
oedema of the lungs. 



DISEASES OF THE LUNGS AND PLEURA. 



321 



The physical 1 signs depend upon the lesions. It is often possible to 
detect all stages of the tubercular process, from early consolidation to 
large cavity, in the same patient. The signs of consolidation have 
been sufficiently dwelt upon. When softening begins, the percussion 
note continues dull and the breathing bronchial ; but it is often difficult 
to make out the quality of the breath-sounds because they are feeble and 
obscured by numerous moist crackling rales and moist subcrepitant 
raJes from disintegration of lung tissue and bronchitis. After the 
patient has coughed several times and expectorated, and then takes a 
long breath, the quality of the breathing becomes perceptible. As the 
lung tissue is further softened and removed by expectoration cavities 
are formed. These, if large enough and superficial, give a tympanitic 
note on percussion, and if there is a communication with a bronchus, a 
cracked-pot sound. The breath-sounds are hollow and cavernous, and 
the rales are bubbling and gurgling, or large mucous rales. The normal 
vocal resonance is replaced by bronchophony and pectoriloquy. Tactile 
fremitus may or may not be increased (see Cavities, page 263). 

But if the walls of the cavity are thick from indurated tissue the 
percussion note will be dull and the breathing bronchial. If the tissue 
composing the wall is less thick and dense, percussion produces a wooden 
sort of resonance. If much normal lung tissue intervenes, the percus- 
sion note will be clear. 

As tuberculosis of the lungs progresses the clavicles and ribs become 
more and more prominent from the loss of fat, and local flattening of 
the chest with impaired expansion marks the seat of the disease. 

The Diagnostic Features. The striking phenomena of tuber- 
culosis which are considered in the diagnosis are emaciation, anaemia, 
fever, cough, dyspnoea, chest pain, hemorrhage, the expectoration, and 
the objective symptoms. Of less diagnostic value, but important as 
collateral data, are the aspect, the occurrence of vomiting and diarrhoea, 
and of symptoms of secondary tuberculosis in other organs. Reliance 
can be placed, to a certain degree, upon such associated circumstances as 
age and occupation, in the formation of the diagnosis. 

Emaciation. This is always seen, even in acute forms of tuberculosis. 
It is rapid in the acute, slow and progressive in the chronic forms. In 
the latter the flesh may be restored for a time. It must not be con- 
founded with muscular atrophy, and the emaciation of carcinoma, dia- 
betes, anorexia nervosa, and other exhausting diseases. Anwmia is always 
pronounced. It may be associated with leucocytosis. The reduction 
of reel cells and diminution of haemoglobin are marked. Fever. This 
symptom is always present. The temperature should be taken every 
two hours for a time, to determine accurately the degree and course. 
It may be intermitting, remitting, or continuous. It may be intermit- 
ting in some acute forms, the morning fall reaching or going below 
normal. The difference between morning and eveniug temperature may 
not be more than a degree. In the acute forms it is high and continuous, 
and soon may be attended by the typhoid state. In the more chronic 
cases it may be intermittent at first, then continuous, and finally inter- 
mittent again. In the later stages the intermitting fever is due to 
a mixed infection, or sapraemia, from the purulent contents (staphylo- 

21 



322 



SPECIAL DIAGNOSIS. 



coccus and streptococcus infection) of the lung cavities 1 (see Fig. 57 
and Fig. 58). The intermittent fever of the early stages has frequently 
been mistaken for malaria (see Fever). The occurrence of fever in a 
patient who has been losing flesh, and is otherwise in poor health, excludes 
cancer and diabetes and other afebrile causes, and points strongly to 
tuberculosis. It must not be forgotten that in chronic tuberculosis in 

Fig. 57. 



"_M E M E M E M | E M | E M E M j E M | E ME ME M E M | E M|E M | E M | E M~["e~ m!e|m|e|m|e|m|e |m|e 




Continued fever of tuberculosis. 



Fig. 58. 




Intermitting fever of tuberculosis. 



the aged the temperature may not rise above 100° ; often, indeed, it is 
subnormal. 

We must consider, therefore, that fever, the cause of which is not obvi- 
ous, may be due to tuberculosis ; that, if not controlled by allaying proba- 
ble causal conditions, as gastro-intestinal catarrh or infectious disorders, 



1 Leyden has recently pointed out that intermitting fever is part of the tuberculous process and 
not a strepto- or staphylococcus infection as formerly held, because pus micro-organisms are not 
found in the purulent contents of cavities, and because in other forms of tuberculosis, as em- 
pyema or joint disease, they are notably absent, and yet such form of fever exists.— Deutsche 
medicin. Wochenschrift, Sept. 14, 1894. 



DISEASES OF THE LUNGS AND PLEURJ1. 323 



as malaria, or relieving suppurations, it is more probably of tuberculous 
origin. 

Sweats. Sweating, which is frequent, may be the first symptom com- 
plained of by the patient. It may occur with the tripod of symp- 
toms of the intermitting febrile range — chill, fever, and sweat. It would 
be likely to occur at night under these circumstances. It may occur 
at any time, however. " Night-sweats " are alarming to the mind of 
the laity, and truly of diagnostic significance. The perspiration awakens 
the patient at night because it is so profuse. It may be moderate only, not 
rousing the patient until morning. It may be general or local. Local 
sweats are confined to the head and neck. Anaemia. This quite rapidly 
becomes marked. It is recognized by the color of the surface and by 
an examination of the blood. When collateral inflammation is present, 
leucocytosis is seen. Cough. Cough is one of the earliest symptoms. 
It may be the single symptom for some time. It is often dry and 
hacking at first. Such dry cough may continue for a long time. 
Later, it is accompanied with mucoid and then muco-purulent sputa, 
which contain the characteristic elements (see Sputum). Dyspnoea is 
almost always present. The degree varies with the association of 
fever. When the latter is present, dyspnoea is more pronounced. It 
is more pronounced in acute cases. In miliary tuberculosis the fre- 
quency of respirations that attends the dyspnoea is out of all proportion 
to the physical signs. In this form, cyanosis is more marked. In 
chronic localized phthisis, the dyspnoea may only occur on exertion, 
after eating, or upon excitement. The bloodless lips may have a con- 
stant bluish hue. The fingers are dusky and become "clubbed." In 
the later stages the dyspnoea is constant and in proportion to the 
extent of involvement of the lungs and the degree of fever. Although 
of diagnostic significance only with other symptoms, it is most distress- 
ing, and is the cause of constant demand for relief. 

Chest Pain. This is due to localized pleurisy or to myalgia. 
The latter may be seated in muscles strained by coughing. Pleuritic 
pains may occur in any situation, and vary in position from time 
to time. They may be due to extensive inflammation or to tuber- 
culous pleurisy. Constantly recurring and unilateral chest pains, with 
or without signs of pleurisy, with cough and emaciation, are significant 
of the disorder under consideration (see Pain). Hemorrhage. This 
symptom is alarming, and, in the large majority of cases, due to pulmon- 
ary tuberculosis. It may mark the onset of the acute disease, and con- 
tinue irregularly throughout its course or recur several times before the 
advent of more common symptoms of the chronic form. It may occur 
at intervals of a few months, or a year, before emaciation, cough, and 
characteristic expectoration set in, or before bacilli are found in the 
sputum. Each attack is attended by fever, usually, and followed by 
anaemia and prostration. If hemorrhage of the lungs (see Symptoms) 
occurs in a young adult without cause (as aneurism or cardiac disease, 
etc.), it must be looked upon with suspicion. The likelihood of tuber- 
culosis is increased if the bleeding occurs in a patient of tuberculous 
aspect, in whom a family history of tuberculosis is found, and who has 



324 



SPECIAL DIAGNOSIS. 



been exposed to infection. In the aged it may occur from a localized 
area of disease. 

Hemorrhage is also common in the late stages of tuberculosis. It 
is not at this period of diagnostic value as to the primary cause. It is 
usually due to the erosion of an artery in a cavity. 

Hemorrhage also occurs in tuberculosis in the quiescent period. The 
progress of the disease is arrested. The discharge of blood is accom- 
panied by the expectoration of pulmonoliths, calculi formed by the 
degeneration of caseous areas. 

The Sputum (q. v.). The diagnosis is absolute when tubercle bacilli 
are found in the expectoration. Nummular sputa are more common in 
phthisical excavation. The sputum is discharged in tough coin-shaped 
masses which sink when expectorated into a vessel containing water. 
Fragments of lung tissue (yellow elastic) point to tuberculosis, but are 
possible under other circumstances. 

The Physical Signs. The objective signs point to invasion of air- 
containing structure by solid material, with collapse of lobules, to 
consolidation and to cavity formation, and to the secondary occurrence 
of pleurisy. In the chronic cases, contraction, lessened movement, 
dulness and increased resistance from thickened pleura may override 
the signs of consolidation. No one physical sign is of diagnostic sig- 
nificance. The combination of signs, and the orderly procession by 
which they advance as the physical conditions progress, are the most 
diagnostic. Local contraction (flattening) and impaired movement at 
an apex, with suppressed breath-sounds and prolonged expiration, with 
impaired resonance, are the earliest signs of tuberculosis. 

The aspect of the patient is always suggestive, and is an aid to the 
recognition of the condition. The tuberculous or phthisical chest, the 
long neck and arms, the pale face, the occasional hectic flush, the 
clubbed fingers, the emaciation, of the many subjects we see in our in- 
firmaries, fix in our minds a composite picture the recognition of which 
in individual cases goes far to diagnosticate the insidious disease. 
Vomiting (see Gastro-intestinal Disease) is a symptom which is often 
present in the early stages of tuberculosis of the lungs, and frequently 
masks the true condition. The vomiting may lead to the belief that a 
local gastric catarrh or diarrhoea is to blame for the general symptoms. 
The occurrence of fever with the gastric symptoms should lead to an 
examination of the lungs. 

The occurrence of diarrhoea and symptoms of tuberculosis in other 
organs may thoroughly establish a diagnosis in tuberculosis of the 
lungs with otherwise obscure pulmonary symptoms. The intestinal 
discharges may contain tubercle bacilli, or the latter may be found in the 
urine in joint suppuration or glandular enlargement. 

In addition to the above we might carefully associate circumstances. 
The age is inquired for, adolescence and early adult life being the 
common periods in which pulmonary tuberculosis develops. The occu- 
pation, 1 the history of exposure to the disease, the history of predispo- 

1 Several undoubted instances are recorded in which hospital residents and young physicians 
working in laboratories in which tuberculosis is studied, or constantly examining sputum, have 
been infected in the course of their studies. 



DISEASES OF THE LUNGS AND PLEURJ1. 



325 



sition to tuberculosis in the family, the history of previous, now 
arrested, tuberculosis, as in joint disease, or glandular tuberculosis 
(scrofula), are data deserving special consideration, which are corrobo- 
rative evidence of the presence of the disease. 

The Diagnosis is Established by Finding Tubercle Bacilli in the 
Sputum. Their absence, careful search having been made, is against the 
tuberculous origin of the disease. 

In subsequent chapters the differential diagnosis of tuberculosis and 
other diseases will be pointed out. It must not be forgotten that the 
disease may set in and be the terminal affection in many diseases. 
Thus, in diabetes, in insanity, in chronic cerebral or spinal disease, and 
in other affections, tuberculosis may develop insidiously, and finally 
cause death. 

It must be distinguished from chronic gastric disorders, and particu- 
larly anorexia nervosa. It must not be confounded with malaria. 
It must be distinguished from simple anaemia, the cause of which may 
be recognized with difficulty. It must be distinguished from chronic 
bronchitis with bronchiectasis, from pulmonary gangrene and carcinoma. 
Finally, it must not be mistaken for cancer of the oesophagus and aneur- 
ism of the aorta, two divergent conditions which may have pulmonary 
symptoms simulating phthisis. 

Gangkene of the Lung. 

Gangrene is a rare disease of the lung, and, like abscess, always 
secondary. It may be produced by any cause which so obstructs the 
circulation that a portion of lung dies in bulk. The gangrene may be 
circumscribed or diffused ; it results most frequently from pneumonia, 
but may be due to injury, to a general septic condition, or to embolism. 
It is relatively frequently met with in the insane, possibly owing to 
particles of food which have found their way into the lung. Aspira- 
tion broncho-pneumonia, bronchiectatic and tuberculous cavities, some- 
times lead to gangrene. Gangrene in the lung, as elsewhere, occurs in 
diabetes. 

Symptoms. When it occurs in the insane or is of embolic origin it 
may remain latent, aud in septicaemia it may be overlooked on account 
of the general symptoms. In well-marked cases, however, the symptoms 
are characteristic. Symptoms and physical signs of pulmonary disease 
precede the specific symptoms of gangrene. With the onset of a mod- 
erate fever haemoptysis may occur at once or be preceded by the expecto- 
ration of a brownish, purulent sputa having a most intense and per- 
sistent gangrenous odor. It contains fragments of lung tissue, altered 
blood, and putrid debris. (See Sputum.) It separates into the three 
characteristic layers in a conical glass. The foetor of the breath aud 
sputum is diagnostic. 

The disease usually occupies the lower or middle lobe of the lung. 
The physical signs are those of cavity. The disease could with diffi- 
culty be distinguished from abscess except for the characteristic sputum, 
though in gangrene there is greater tendency to a general septic condi- 
tion, with profuse sweats and collapse. 



326 



SPECIAL DIAGNOSIS. 



Abscess of the Lung. 

Abscess of the king may originate in causes outside the lung, or in 
causes within the lung. To the former class belong those produced by 
suppurating bronchial glands, abscess of the mediastinum opening into 
the lung, cancer of the oesophagus with ulceration, and abscess of the 
liver, suppurating hydatid cyst, or sub-diaphragmatic abscess in general, 
bursting into the lung. Intra-pulmonary causes are tubercle, septic 
emboli, in which case the abscesses are multiple and sub-pleural, and 
pneumonia. In the aspiration form of lobular pneumonia abscesses 
occur. Rarer causes are the presence of tumors and obstruction of the 
bronchi. 

Abscess of the lung is therefore always secondary. Its diagnosis 
depends upon the demonstration of a cavity taken in connection with 
the history pointing to a cause. The sputa are copious, purulent, often 
odorless, sometimes offensive but always without the foetor of gangrene. 
They contain elastic fibre, but no bacilli except in tuberculous cases 
(see Sputum). In embolic abscess the signs of pleural friction can only 
be detected at times. 

Collapse of the Lung. 

Collapse of the lung is a condition produced by exhaustion of air 
from the air-vesicles. It may affect alveoli here and there, or a large 
section of the lung. Formerly such collapse was invariably looked 
upon as pneumonia until Legendre and Bailly proved by forcible infla- 
tion that the air-vesicles had simply collapsed from absence of air. 
Collapse occurs most frequently in the course of bronchitis and in cases 
with feeble respiratory power. The bronchial twigs supplying certain 
air-vesicles, or tubes supplying sections of lung, become occluded to 
such a degree that no air can enter. The air already contained in the 
vesicles then becomes exhausted gradually until the vesicles are com- 
pletely airless. The vesicles or sections of lung involved then return 
to their foetal condition. When the' collapse is congenital the term 
atelectasis is preferable. Anything which induces great muscular 
weakness predisposes to collapse of the lung ; hence in the aged and 
feeble, in wasting diseases, and in low febrile diseases of long standing, 
collapse is very liable to occur. But bronchitis is the most frequent 
and direct cause. The secretions which are poured out, and the swell- 
ing of the mucous membrane, occlude the tubes, and if the patient have 
not strength enough to expel the secretions, and, by forced inspiration 
expand the collapsing vesicles, collapse ensues. 

Diagnosis. The diagnosis of the condition in life is difficult. The 
area of collapse, being airless, is, of course, dull on percussion. The 
respiratory murmur is more likely to be faint or absent than to be in- 
creased in intensity or approach the bronchial. Nevertheless there is 
sometimes heard a faint broncho- vesicular expiration. 

When oedema is superadded to collapse, moist crepitant rales are 
heard, difficult if not impossible to distinguish from those of pneumonia. 
Respiration is embarrassed, and is accompanied by sucking in of the 



DISEASES OF THE LUNGS AND PLEUBJ. 



327 



lower part of the chest in inspiration. Sometimes the plug of mucus 
which occludes the tubes becomes dislodged while the physician is aus- 
cultating, and then the respiratory murmur will be heard accompanied 
by a succession of crepitant rales, which disappear after a few inspira- 
tions. The dull areas, as a rule, are less persistent than those of pneu- 
monia ; thus it may be found at successive examinations that one area 
has cleared up and another has become dull. Stress is laid by some 
writers upon the signs of emphysema surrounding collapsed areas. But 
this does not give assistance in the cases in which most help is required 
— cases in which there is diffuse bronchitis with more or less oedema. 

Subjective symptoms are those of dyspnoea and deficient oxygenation 
of the blood. If these are developed suddenly, and are accompanied 
with the appearance of dull areas in the lung without bronchial breath- 
ing, the diagnosis is tolerably certain. But when scattered lobules only 
are involved the physical signs of collapse are absent, and its existence 
must be a matter of inference. 

From lobar pneumonia the diagnosis is generally easily made by the 
difference in the physical signs, and by the absence in pulmonary col- 
lapse of inflammatory symptoms, the lower temperature, and the differ- 
ence in onset. 

The diagnosis from broncho-pneumonia, or catarrhal pneumonia, is 
beset with greater difficulties. But here also the lower temperature and 
the fact that the physical signs and the location of the dull areas are 
subject to rapid changes, is of aid in diagnosis. 

Cancer and Other New Growths of the Lung. 

The new growths may be primary or secondary. The latter are most 
common. Of primary cancer, the epithelioma is most common ; en- 
cephaloid and scirrhus come next. Sarcoma is sometimes primary. 
Secondary new growths succeed disease in the abdominal organs, the 
genito-urinary tract, the bones, the breast, and the eye. 

Symptoms. The general symptoms of malignant growths accom- 
pany the thoracic symptoms. Chest pain, dyspnoea, cough, and a 
peculiar expectoration belong to the latter. The pain is due to associate 
pleurisy ; the dyspnoea is paroxysmal. (See dyspnoea from pressure on 
bronchi.) The expectoration is dark, like prune-juice. Signs of intra- 
thoracic pressure are seen. The external thoracic veins are enlarged. 
The face aud arms may be cyanosed, or one arm only affected. The 
heart may be dislocated, the trachea changed in its course ; compression 
of trachea and bronchus causes dyspnoea. 

Physical Signs. In primary cancer the affection is unilateral; in 
secondary forms, bilateral. The physical signs are those of pleural effu- 
sion or of local consolidation. The consolidation may be massive and 
not partake of the shape of a lobe. Often signs of effusion and consoli- 
dation are combined (enlargement, immobility, absent fremitus, but 
bronchial breathing). In the secondary forms the disease is bilateral. 
The signs are mixed. They indicate lessened air in the lung structure. 
Care must be taken not to overlook the pleural effusion which accom- 
panies the process, the removal of which gives temporary relief. In 



328 



SPECIAL DIAGNOSIS. 



both forms external lymphatic glands, particularly the cervical, may be 
enlarged. 

Diagnosis. The diagnosis is based upon — 1, the age (after forty) ; 
2, the occurrence of emaciation ; 3, the duration of the disease, often 
rapid, rarely beyond eight months ; 4, the presence of primary disease 
elsewhere ; 5, the occurrence of moderate fever ; 6, the signs of intra- 
thoracic pressure ; 7, the involvement of lymphatic glands ; 8, the occur- 
rence of irregular areas of consolidation and of pleural effusion, alone 
or combined ; 9, the characteristic expectoration ; 10, dyspnoea due to 
pressure on the bronchus or trachea ; 11, the absence of bacilli from 
the sputum. 

An effusion often can be recognized only after puncture. Hemo- 
thorax is not necessarily present. 

Hydatid Disease of the Lungs. 

The lungs are affected in about 11 per cent, of the cases of hydatid 
disease. The symptoms, according to Wilson Fox, consist of dyspnoea, 
pain in the chest, cough, occasional hsernoptysis, and sometimes the 
expectoration of hydatids, the sputa being otherwise bronchitic, or pre- 
senting the characteristics of pneumonia or gangrene, when these com- 
plications are present. Gradually weakness increases, sometimes with 
pyrexia, which, when combined with emaciation, may impart to the 
case a considerable resemblance to phthisis ; pressure symptoms occasion- 
ally occur, and the physical signs are either of consolidation of the lung or 
of pleural effusion, together with certain peculiarities depending on the 
size and site of the tumor. Graham states that they are more frequent in 
the right lung and more common at the base, causing marked bulging 
of the thoracic wall. The physical signs are those of pleural effusion 
with localization of the fluid to a definite area, and hence not related to 
the shape of the pleural cavity. The breathing may be tubular ; there 
is condensed lung between the hydatid and the thoracic wall. Cough, 
dyspnoea, anaemia, with emaciation and clubbing of fingers, lead to the 
diagnosis of phthisis. Haemoptysis occurs in many cases. The tempera- 
ture is normal — an important point in diagnosis. If the cyst ruptures 
the sputum is diagnostic. Complications mark the diagnosis often. It 
must be distinguished from pleurisy, localized empyema, pulmonary ab- 
scess, phthisis, and mediastinal tumors. 

Diseases of the Pleura. 

The large lymph structures which cover the lung and line the inside 
of the thorax are often the seat of disease. It is usually of an inflam- 
matory nature. Hence, pleurisy, or pleuritis, is the most common af- 
fection of the pleura. It may be, as to distribution, bilateral or unilateral ; 
as to extent, local or general ; as to the nature of the inflammation, plastic, 
serous or purulent. The inflammation may be acute or chronic. It is 
rarely primary. It arises in the course of general diseases, or is the re- 
sult of the extension of inflammation, chiefly of an infectious nature, 
from neighboring structures. 



DISEASES OF THE LUNGS AND PLEURiE. 



329 



1. Disease of the ribs or vertebrae, diseases of the mediastinum, of the 
aorta, oesophagus, and especially of the lung, give rise to various forms 
of pleurisy, depending upon the nature of the primary affection. 

2. Disease below the diaphragm. Abscess of the liver; perforative 
inflammation of other viscera adjacent to the diaphragm; abscess of the 
spleen or pancreas ; pus in the pelvis or about the appendix, may give 
rise to purulent pleurisy by burrowing of the pus or infection through 
the lymph channels. 

3. Disease of the lungs. In the large majority of cases pleurisy in 
some form occurs in the course of pulmonary disease. In all surface 
inflammations of the lungs there is associate pleurisy. It is seen in 
pneumonia, in tuberculosis, in gangrene, and in abscess. 

Pleurisy may be simple or purulent. Empyema is always due to 
infection from the exterior, as the ribs; from the lungs (pneumonia); 
suppuration below the diaphragm ; or to general infective processes, 
as septicaemia, pyaemia, and tuberculosis. 

The general diseases in the course of which pleuritis arises are usually 
infective or of such nature as to cause irritative products to circulate in 
the blood. Of the former, the most common is tuberculosis ; the next 
most common are septicaemia and scarlatina; while to the latter class 
belong Bright's disease, gout, diabetes, rheumatism, and scurvy. 

Purulent pleurisy is more common in children than in adults ; in 
males than in females ; and more common in tuberculous pleurisy and 
pyaemia than in rheumatism and Bright's disease. 

Acute Pleurisy. 

Acute pleurisy may be primary, or may be secondary to disease of 
the lung, or be part of a general infection. Three stages in the morbid 
process usually occur, although it may be arrested in the first stage. 

Symptoms of the First Stage. Dry Pleurisy. The onset of 
the disease is usually abrupt, and is marked by fever, which may or 
may not be preceded by chill, and is followed by pain in the side, 
dyspnoea, and cough. The pain is sharp, stabbing, or tearing in char- 
acter, and is usually, but not always, referred to the seat of pleurisy. 
This is most frequently on a level with the nipple, or a little below this, 
and oftener anteriorly or in the axilla than posteriorly. The pain is 
caused by the rubbing together of the inflamed surfaces of the pleura, 
and hence is excited by respiration and cough. For this reason the 
patient is inclined to restrict the motion of the affected side as much as 
possible ; he does this by leaning over toward that side and by pressing 
his elbow in against the chest wall. Pain is usually the first symptom 
noticed by the patient. The cough is dry and painful. Fever is moderate. 

The physical signs in primary cases are a friction , sound heard on 
inspiration and expiration. This friction sound may be a nest of fine, 
dry, crepitant r&les, which are very superficial, and appear to be just 
under the ear ; or a coarse rubbing sound, heard over a larger surface, 
and resembling a bronchial rhonchus, from which it can be distinguished 
by its persisting after the patient has coughed. The lungs themselves 
present nothing abnormal. 



330 



SPECIAL DIAGNOSIS. 



If the inflamed surfaces become glued together by plastic lymph, re- 
covery usually occurs very soon, though pain often persists for a long 
time in lessened degree, and the pleurisy is liable to be re-lighted. 

Symptoms of Second Stage, or Stage of Effusion. If effusion 
takes place the two layers of the pleura become separated ; hence pain 
and friction sound cease, and physical exploration shows that a collection 
of fluid intervenes between the chest wall and the lung. The physical 
signs of this stage are (L) enlargement of the affected side, increase in 
semi-circumference, with fulness of interspaces ; (2) diminution of 
movement; (3) absence of vocal fremitus and resonance; (4) dulness 
or flatness (deadness) on percussion, with great increase in the resistance 
to the pleximeter finger ; (5) absent or greatly diminished respiratory 
murmur ; (6) displacement of organs. 

The dead percussion note being caused by fluid, it follows that the 
upper level of it will change with the position of the patient if the fluid 
is free. If the upper level is at the third interspace when the patient 
is sitting up, it will fall to the fourth or lower when he is lying down. 
This change of level cannot be appreciated when the effusion is very 
large. Moreover, above the line of dulness the percussion note is 
hyper-resonant or tympanitic — Skoda's resonance. Toward the spine 
on the affected side there may be partial resonance and bronchial breath- 
ing, because here the lung is compressed against the vertebra?. In large 
effusions the tympanitic resonance in the second interspace does not 
change when the mouth is opened. u Williams' tracheal tone" can 
often be elicited in large effusions. The upper limit of dulness in 
large pleural effusions is higher at the spine and slopes downward, and 
is lowest in front. In moderate effusions the line of dulness is lowest 
near the spinal column, rises in the middle of the scapula and slopes 
downward, assuming the shape of the letter S as it passes toward the 
front (Garland). The patient should take deep breaths before the per- 
cussion is performed. At the left base in front the semilunar space is 
removed, dulness continuing to the margin of the ribs. 

Below the upper level of the effusion posteriorly the voice frequently 
has a metallic quality resembling the bleating of a goat — a^gophony. 
It occurs usually when the effusion is moderate, and may be heard only 
over a limited area. It is commonly heard at or above the angle of the 
scapula. 

While the respiratory murmur is, as a rule, absent, breath-sounds 
may be heard, and are then usually bronchial. In such cases there may 
or may not be adhesions. Bronchial breathing may be preseut along 
the spine in small effusions, and in large effusions in the inter- 
scapular region. Bronchial breathing, tubular in character, is said to 
be almost constant in children. It may also occur when pneumonia 
coexists. 

At the level of the fluid a friction sound may persist. Above the 
level of fluid anteriorly the breath-sound may be bronchial or broncho- 
vesicular, associated sometimes with fine rales, due to compression and 
slight oedema. 

Displacement of Organs. If the effusion is on the left side the medi- 
astinum and heart become displaced to the right, and the apex beat may 



DISEASES OF THE LUNGS AND PLEURJ. 



331 



be found in the epigastrium, or even to the right of this. At the same 
time the semilunar space (Traube's liue) is lower than usual or entirely- 
effaced. If the effusiou is on the right side, the diaphragm, and with it 
the liver, is depressed, and the mediastiual contents moved to the left. 

The subjective symptoms during this stage are slight or moderate 
fever, sometimes intermittent in character, with recurring chills ; con- 
siderable dyspnoea, occasionally amounting to orthopncea when the 
effusion is very extensive ; and dry cough, which adds greatly to the 
dyspnoea. There is frequently some evidence of defective oxygenation 
of the blood ; when this amounts to cyanosis, the condition is one of 
great danger. The urine presents changes in amount. In advancing 
effusion, the amount lessens very much ; it increases in amount with 
the decline of the fluid. Pleurisy may be complicated with bronchitis, 
pneumonia, and pericarditis. 

Empyema. The above-mentioned physical signs apply chiefly to 
serous effusions. They are also present in effusions of pus. In addi- 
tion, other physical phenomena and different general symptoms distin- 
guish the two kinds of effusions, although it must be confessed that 
aspiration must often be resorted to. 

The physical signs of empyema are the same as those of other effusions 
within the pleura. In addition, especially in children, local oedema of 
the chest- wall may be found. Another sign was pointed out by Bacelli, 
and is held by others to be of diagnostic significance. In purulent 
effusions the fremitus produced by the whispering voice is not trans- 
mitted to the hand laid over the effusion, whereas in serous effusions 
such vibrations are transmitted. In empyema a local area may become 
more prominent and the surface assume an inflammatory appearance. 
It is an indication of discharge of the abscess through the chest wall. 
It is usually found in the fifth interspace in front, or below the angle 
of the scapula behind. (For a microscopical and chemical description 
of the " Effusions within the Pleural Sac," and of the morphological 
elements of the purulent effusions, see Chapter V.) 

The general symptoms are more marked in empyema than in simple 
serous effusion. The temperature is higher from the onset. It soon 
becomes intermittent or remittent. Chills or chilliness may attend the 
beginning of each febrile paroxysm, and sweats occur with the daily fall 
of temperature or at irregular periods during the twenty-four hours. 
The heart's action is more rapid and the pulse more feeble, and it soon 
becomes dicrotic. Examination of the urine may aid in the distinction 
of the two forms of the effusion. Peptonuria occurs in purulent pleu- 
risy. It must be remembered that peptonuria occurs in suppuration 
from other causes. Thus, in phthisis with suppuration of a cavity 
pleural effusion may develop. The peptonuria that attends the primary 
process must not be mistaken for that which occurs in empyema. 
Indican is also present in excess in the urine in suppurations. Before 
a decisive conclusion is arrived at two or more examinations of the 
urine should be made. Examination of the blood may aid in arriving 
at a conclusion. In purulent effusion there is usually a leucocytosis. 

Notwithstanding the positive physical signs of effusion the character 
of the effusion may not be recognized until perforation into the bronchus 



332 



SPECIAL DIAGNOSIS. 



has taken place. The peculiar character of the expectoration that 
attends this accident is described in the section on Sputum. 

Hydro-thorax. This is an accumulation as the result of a transu- 
dation. (For character of the fluid, see Chapter V.) It occurs in the 
course of diseases which produce anasarca, as failing organic heart 
disease, chronic Bright's disease, and debilitating diseases, as scurvy. 
Locally it may attend carcinoma of the pleura or obstructive disease 
of vessels within the mediastinum. 

The physical signs of hydrothorax are those of effusion in acute 
pleurisy. The general symptoms belong to the primary disorder. Dys- 
pnoea may develop gradually and even amount to orthopnoea. It is 
distinguished from inflammatory effusions by the character of the fluid, 
by the absence of the general symptoms of inflammation, by its insidi- 
ous development, and by its bilateral distribution. 

Hemothorax. The transudation of blood into the cavity of the 
pleura occurs rarely from the rupture of an aneurism into the sac. 
The fluid is then pure blood. Serous effusions in which a large amount 
of blood is found point to primary carcinoma of the pleura, or to 
tuberculous disease. Both specific processes of this serous membrane 
may occur, however, without the transudation of sero-bloody fluid. 

Thickened Pleura. Chronic inflammation, with thickening of 
the pleura from excessive development of connective tissue, occurs in 
tuberculosis and in cases of combined pleuritis and peritonitis. The 
physical signs are pronounced and are those of effusion without enlarge- 
ment of the chest. The thickening of the pleura is usually more 
marked at the base. On inspection there is marked contraction and 
diminution in movement of the affected side. The fremitus is absent. 
There is dulness on percussion, or even flatness. The breath-sounds are 
distant or are absent entirely. Along the vertebrae, especially opposite 
the angle of the scapula, bronchial breathing may be heard. The sub- 
jective symptoms of cough and dyspnoea are present. The degree of 
cough depends upon the condition of the parenchyma of the lung. If 
there is bronchitis or tuberculosis, the cough is excessive. The amount 
of dyspnoea depends upon the degree of compression of the lung by the 
thickened pleura. 

Tuberculous Pleurisy. The affection may be acute or chronic. It 
may occur primarily, be a part of general tuberculous infection, or 
occur secondarily to disease of the lungs. It may give rise to all forms 
of the inflammatory process. First, dry pleurisy ; second, pleurisy with 
effusion ; third, pleurisy with great thickening, may be found. The 
distinction between tuberculous pleurisy and pleurisy due to other 
causes can often not be positively determined. If it is associated with 
tuberculosis in other organs, or the patient is of tuberculous habit and 
exposed to infection ; or, if there has been a history of previous tuber- 
culosis, the pleuritic infection is probably of tuberculous origin. If the 
affection is bilateral and associated with peritoneal inflammation, and 
at the same time no other cause exists for serous membrane inflamma- 
tion, the probability of its tuberculous origin is very strong. 

Pulsating Pleural Effusion. Wilson has presented the most 
recent studies of this rare affection. The effusion within the pleura pnl- 



DISEASES OF THE LUNGS AND PLEURJ3. 



333 



sates synchronously with the ventricular systole; the pulsation is detected 
usually by inspection and palpation. In some instances its presence 
is only determined by palpation. It may be confined to two or three 
interspaces or occupy the anterior aspect of the thorax and the axillary 
region on the left side. Rarely the pulsation is behind. It is usually 
situated on the left side. The original effusion is purulent in the large 
majority of cases. The physical signs and general symptoms of empy- 
ema are present. Nevertheless the disease simulates aneurism of the 
aorta. The latter affection, however, is accompanied by vascular symp- 
toms and physical signs discovered in the course of the aorta. Pul- 
sating empyema is distant from the aorta. 

Diaphragmatic Pleurisy. In diaphragmatic pleurisy there is 
intense pain in the epigastrium. Gueneau de Mussy 1 regards a pain 
along the tenth rib, extending from the anterior extremity to the 
sternum and xiphoid cartilage, as pathognomonic. Other symptoms 
are nausea, vomiting, and hiccough. The dyspnoea often amounts to 
orthopuoea, or the patient sits stooping forward. The anxiety of the 
patient is very great. The fever is usually higher than in ordinary 
pleurisy, and there may be delirium. Effusion may lessen the pain. 
Peritonitis may occur at the same time, or be secondary to the pleurisy. 

Diagnostic Features. The special features of diagnostic impor- 
tance that are observed in the course of pleurisy are the pain, the 
dyspnoea, the cough, the fever, the physical signs of effusion within the 
pleura, and the results of exploratory puncture. Pain : The pain is 
short, sharp, lancinating, aud from its character and location is usually 
readily recognized. It must be distinguished from the pain due to pleu- 
rodynia and intercostal neuralgia. The pain of pleurisy is associated 
with cough and is increased by breathing. It causes diminution of 
movement of the affected side. The patient is compelled to sit up in 
bed or lie on the side which is the seat of pain. Cough: In the first 
stage the cough is short, suppressed, dry and painful. It is constant. 
In the second stage it changes in character. There is no pain, there is 
no expectoration. It is frequent and irritating and of a peculiar sound 
which is difficult to describe, and yet, when once heard, is most sugges- 
tive in subsequent cases. It is short and lacks resonant quality, as if 
the fluid in the chest stopped the sound waves. Dyspnoea in the first 
stage is due to pain, in the second stage to the large effusion which 
encroaches upon the normal air-space. It is not diagnostic. The 
physical signs of pleural effusion have been frequently reiterated. 
The most decisive are diminution or absence of movement, enlarge- 
ment of the affected side, absence of fremitus, flatness on percussion, 
fulness of intercostal spaces, and the displacement of organs. The 
latter is of the greatest diagnostic importance in the distinction between 
consolidation and effusions. The results of exploratory puncture lead 
to decisive conclusions usually, although it must not be forgotten that 
effusions may be loculated and by accident not secured by the aspirating 
needle. Or the enormously thickened pleura may intervene between 
the exudation and the surface of the chest, and prevent withdrawal of the 

1 Arch. Gen. de Med., 1853, vol. xi. Quoted by Fox. 



334 



SPECIAL DIAGNOSIS. 



fluid. Finally, effusions may complicate inflammatory processes, as 
pneumonia, tuberculosis, or abscess of the lung. To secure fluid for 
diagnosis by aspiration, therefore, does not necessarily exclude these 
conditions, and hence, before the process is decided to be within the 
pleura alone, the sputum and other conditions must be taken into con- 
sideration. 

Differential Diagnosis. Acute plastic pleurisy is diagnosticated 
from acute pneumonia by the friction sound and the maintenance of the 
clear percussion note and normal respiratory murmur, with unaltered 
vocal resonance and fremitus. When effusion takes place the chest is 
enlarged and immobile, especially on the affected side, the interspaces 
are filled out and the diaphragm is depressed; these changes do not 
occur in pneumonia. Moreover, the percussion note in pleural effusion 
is flat, with greatly increased resistance; the shape of the upper line of 
dulness is diagnostic ; the respiratory murmur is feeble and distant, or 
entirely absent, except along the spine, where the compressed lung yields 
bronchial breathing, and also above the line of effusion, where the 
lung yields exaggerated breathing. In pneumonia, on the other hand, 
the percussion note is dull, without greatly increased resistance, and the 
breath-sounds are bronchial. In addition, in pleurisy, the vocal reso- 
nance and fremitus are usually almost if not quite absent, and pos- 
teriorly at the level of the effusion, segophony may be detected. In 
pneumonia, on the contrary, vocal resonance and fremitus are increased 
in intensity. In pleurisy with effusion the movable organs are dislo- 
cated and Traube's line is obliterated. 

Finally, the fever of pneumouia is much higher and more continuous 
than that of pleurisy, the respirations more frequent, the cough looser 
and in typical cases followed by rusty sputa. A crucial test is aspira- 
tion with a hypodermic needle; in pleural effusion, serum is withdrawn ; 
in pneumonia, a few drops of thick blood. 

In pleurodynia there is also severe pain in one side. But the pain 
is more continuous than that of pleurisy, and consists of a constant 
aching or a burning sensation. It is made worse by twisting or 
turning, as well as by breathing. The side is also tender to the touch. 
The pain is not so sharply localized as that of pleurisy, and may leave 
one side and affect the other. It is unaccompanied by fever or friction 
sound, and is frequently found in rheumatic subjects. 

In intercostal neuralgia there is the same absence of fever and fric- 
tion sound. The pain, however, is sharply localized as in pleurisy, but 
is of the darting neuralgic character, and is associated with tenderness 
at the points of exit of the intercostal nerves. It is most common in 
women, especially if they have uterine disturbances. It is more fre- 
quent on the left side, and just beneath the mammary gland. 

Chronic Pleurisy. 

Chronic dry, or plastic, pleurisy is the result of an acute attack, or 
develops insidiously if tuberculous. It causes great deformity of the 
chest from contraction and compensatory emphysema of the healthy 
lung. The heart is dislocated or cannot be found on physical examina- 



DISEASES OF THE LUNGS AND PLEURJ. 



335 



tion, because it is overlapped by lung or is drawn behiDd the sternum. 
There is considerable spinal curvature, dislocation of the scapula, 
deformity of the shoulder, and indrawing aud overlapping of the ribs 
at the base of the chest. 

Chronic pleurisy with effusion results from an acute attack of pleu- 
risy, in which the fluid remains uuabsorbed, or from subsequent attacks. 
The physical signs are the same as in acute effusion. So far as subjective 
symptoms go it may remain latent ; patients so affected not infrequently 
go about their work with comparatively little dyspnoea. There may be 
an evening rise of temperature and acceleration of the pulse. Chronic 
effusions are more likely to be purulent in children than in adults. 
When empyema results, the fever becomes hectic ; there are chills and 
sweats, pysemia develops, and death is liable to occur from some inter- 
current suppuration, as cerebral abscess. 

After chronic effusion the chest is rarely restored to its original shape 
even if the effusion be absorbed finally. The affected side becomes 
motionless and retracted. In process of time the spine may be bent. 
The opposite lung becomes hypertrophied. The patient is usually in 
precarious health, liable to acute attacks of pain in the affected side, 
and liable also to be carried off by phthisis or some intercurrent affec- 
tion. Rarely the patient may maintain good health, and even cure, 
with restoration of the retracted side to, or almost to, normal dimen- 
sions, is possible, especially in children. 

Pneumothorax. 

Pneumothorax consists in an accumulation of air in the pleural 
cavity, accompanied or followed by an outpouring of fluid, which may 
be serous or purulent, constituting respectively hydro-pneumothorax and 
pyo -pneumothorax. 

Pneumothorax may originate : 1. From causes external to the chest, 
by perforation of the chest wall and pleura. 2. From perforation of 
the lungs, bronchi, or oesophagus. 3. Gases developed from an existing 
effusion. 

The most frequent cause is tubercular disease of the lung, and next 
an empyema; out of 121 cases collected by Saussier, 81 were due to 
phthisis and 29 to empyema. It may occur very early in tubercle of 
the lung, and even be the first symptom of tubercular disease (see cases 
referred to by Fox and recorded by Louis and Chomel). The left side 
is affected not quite twice as often as the right ; the disease is usually 
unilateral. The onset of the condition is usually sudden. During a 
paroxysm of coughing or vomiting, or without immediate cause, there is 
an escape of air into the pleura, and in the majority of cases the patient 
at once complains of acute pain in' the chest and excessive dyspnoea 
with great dread of impending suffocation. The patient often sinks 
into collapse from shock, but sudden death is rare. If the escape of 
air into the pleura is gradual there will be less pain and dyspnoea. 
The chest is distended, especially on the affected side ; the percussion 
note is a bell-like tympany, except when the distention is excessive and 
the air contained is under great tension, when the note is proportion- 



336 



SPECIAL DIAGNOSIS. 



ately duller and higher in pitch; the diaphragm is depressed and the 
heart displaced unless adhesions prevent it. In left pneumothorax it 
may beat on the right side, the whole mediastinum being pushed to the 
right; in right pneumothorax the mediastinum may be pushed to the 
left nipple; hence there is resonance over the normal cardiac region. 
The pitch of the percussion note may be raised when the mouth is 
closed, and lowered when it is open (Wintrich's change of note), and 
a cracked-pot sound can be elicited in some cases, but this occurs only 
when the communication with the pleura remains open. 

A valuable sign of pneumothorax is the coin test. A silver coin 
is laid upon the chest and struck by another, while the auscultator 
applies the stethoscope opposite to the point struck or over any part of 
the side distended by air. The ringing coin sound is reproduced with 
great intensity. It is pathognomonic, and the outlines of the cavity 
can be traced by it. 

When fluid is present, as it usually is, there will be the ordinary 
signs of a pleural effusion, which have been sufficiently dwelt upon. 
The fluid is more mobile in pneumothorax, however, than in simple 
pleurisy, so that its level changes more quickly with change of posture 
of the patient, aud Hippocratic suceussion is readily obtained. 

As the lung is compressed against the spine by the air, as it is by 
the fluid in pleurisy, the breath-sounds are feeble or absent, except 
over the root of the lung, where the breathing is bronchial. But if 
the lung is not completely collapsed, amphoric breathing may be heard, 
the air-chamber of the pleura acting as a consonance-box ; it may be 
heard with both inspiration and expiration, or only with expiration. 

Metallic tinkling is a sound believed to be due to the vibration of 
bubbling bronchial rales re-echoed through the air-chamber, or to drops 
of fluid falling from above upon the surface of the effusion. Re-echo- 
ing with metallic quality may also accompany the heart sounds, and in 
cases in which the respiratory murmur is amphoric the vocal reso- 
nance is of the same character. Vocal fremitus is generally absent. 
The prognosis of the affection depends upon the cause. Traumatic 
cases and those resulting from empyema are more favorable than those 
resulting from tubercle. In the latter cases death may occur suddenly 
from shock, or after a short time; or at times it may have a favorable 
influence upon the lung condition. Generally, however, it hastens 
death. When perforation has resulted from abscess or gangrene, the 
prognosis is very unfavorable, and in the latter case practically fatal. 

Differential Diagnosis. Pneumothorax is most likely to be 
confounded with (1) emphysema; (2) tuberculosis of the lungs with 
large cavities ; (3) cases of pleural effusion in which above the upper 
level of the fluid the lung is markedly hyper-resonant ; and (4) abscess 
below the diaphragm containing air (pyo-pneumothorax subphrenicus). 

Emphysema can be distinguished by its slow onset, its relatively 
slight impairment of the general health, by the fact that it is bilateral, 
whereas pneumothorax is almost always unilateral, and by the exist- 
ence of feeble breathing with greatly prolonged expiration. Amphoric 
breathing and resonance, metallic tinkling, and signs of fluid are all 
absent in emphysema. 



DISEASES OF THE LUNGS AND PLEURJ. 



337 



When the pneumothorax is circumscribed the physical signs resemble 
those of pulmonary cavity. But over a large cavity the chest is usually 
flattened; cracked-pot sound and alteration in pitch upon opening and 
closing the mouth are more common in cavity than in pneumothorax. 
Displacement of viscera does not occur in phthisical cavity, the coin 
test is negative, succussion cannot be produced. Fremitus is absent in 
pneumothorax and increased over a cavity. 

The hyper-resonance above a pleural effusion develops with a very 
different clinical history, is accompanied by increase of fremitus with 
bronchial or, at times, amphoric breathing, and changes when the 
patient's mouth is open or closed. The percussion note usually loses 
the metallic quality heard in pneumothorax, metallic tinkling is absent, 
the coin test is negative. 

Pneumothorax must be distinguished from abscess below the dia- 
phragm containing air (pyo-pneumothorax subphrenicus). Often the 
distinction is difficult. Leyden points out the importance of remem- 
bering the sequence of events in the development of the disease. Where 
the abscess was situated below the diaphragm abdominal symptoms pre- 
ceded its development, and early in the course of the disease there was 
absence of respiratory symptoms. Moreover, in subphrenic abscess 
the heart is not displaced or the interspaces bulging. In pneumothorax, 
according to Leyden, the respiration is normal, under the clavicle, and 
the transitions from the normal to the metallic and amphoric sounds 
lower down are abrupt. In pyo-pneumothorax on the left side the 
semilunar space disappears. In subphrenic abscess the amphoric sounds 
may be above and below the diaphragm or loudest at the epigastrium. 
In addition, in pyo-pneumothorax subphrenicus, as Mason points out, 
adhesions of the lung to the diaphragm and parietes may be made out, 
particularly if the case has been under observation in its earlier stages 
and dry pleurisy discovered. Abscess in this location and slight fluc- 
tuation are likely to develop with associated effusion. The very small - 
ness in size of the effusion is of diagnostic import in favor of sub- 
diaphragmatic inflammation. 



22 



CHAPTEE III. 



DISEASES OF THE HEART, THE BLOODVESSELS, AND 
THE MEDIASTINUM. 

The Heart. 

Before the discussion of the symptoms and physical signs of heart 
disease is assumed, a brief review of some essential facts in the anatomy 
and physiology of the heart is of importance. 

Anatomy. The heart is a hollow muscle, composed of four cham- 
bers. The muscle is made up of unstriped fibre (involuntary muscle). 
The exterior is covered with a serous membrane — the pericardium, 
which is reflected upon the sac in which the heart hangs. The 
interior is lined with the same character of membrane, the endo- 
cardium. The chambers are four in number, two auricles and two 
ventricles. The auricles are at the upper portion or base of the heart ; 
the ventricles at the apex. The heart is divided into two sides, the 
right and the left. An auricle and a ventricle of each side are related 
physiologically. The right heart draws blood from the veins and sup- 
plies it to the pulmonic circulation. The left heart belongs to the 
aortic side of the body, the major or arterial circulation, to which it 
sends blood, while it draws blood from the pulmonic circulation. 
Valves. The auricles are separated from the ventricles by valves 
named from their respective positions, the right and left auriculo- ven- 
tricular, or from their form the tricuspid and mitral valves of the right 
and left sides respectively. The valves close during the systole, pro- 
ducing the systolic sound, and open during diastole. The aortic and 
pulmonary valves are seated at their corresponding situations and close 
with the beginning of the diastole, producing the diastolic sound. 

The heart receives its supply of blood from the coronary arteries and 
its innervation from nerve centres in the medulla, and from the sympa- 
thetic ganglia in the heart muscle. 

Topographical Anatomy. The form and position of the heart, 
its relation, and the relation of its anatomical elements to the surface 
of the chest, must be well known to understand the effects of disease 
upon its structure and function, and to recognize its physical alterations. 

Outline of Heart on Chest Wall. 1 To have a general idea 
of the form and position of the heart, map its outline on the wall of the 
chest as follows : 

(a) To define the base, i. e. f the part to which its great vessels are 
attached — draw a transverse line across the sternum, corresponding with 
the upper borders of the third costal cartilages; continue the line half 
an inch to the right of the sternum and one inch to the left. 



1 From H olden : Landmarks, Medical and Surgical. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



339 



(6) To find the apex, mark a point about two inches below the left 
nipple, and one inch to its sternal side. This point will be between the 
fifth and sixth ribs. 

(c) To find the lower border (which lies on the central tendon of the 
diaphragm), draw a line, slightly curved downward, from the apex 
across the bottom of the sternum (not the ensiform cartilage) as far as 
its right edge. 

(d) To define the right border (formed by the right auricle), con- 
tinue the last line upward with an outward curve, so as to join the 
right end of the base. 

(e) To define the left border (formed by the left ventricle), draw a 
line curving to the left, but not including the nipple, from the left end 
of the base to the apex. 

Such an outline shows that the apex of the heart points downward 
and toward the left, the base a little upward and toward the right ; that 
the greater part of it lies in the left half of the chest, and that the only 
part which lies to the right of the sternum is the right auricle. A 
needle introduced in the third, fourth, or fifth right intercostal space 
close to the sternum would penetrate the lung and the right auricle. 

A needle passed through the second intercostal space, close to the 
right side of the sternum, would, after passing through the lung, enter 
the pericardium and the most prominent part of the bulge of the aorta. 

A needle passed through the first intercostal space, close to the right 
side of the sternum, would pass through the lung and enter the superior 
vena cava above the pericardium. 

The best definition of that part of the precordial region which is less 
resonant on percussion was given by Dr. Latham years ago in his 
"Clinical Lectures." Make a circle of two inches in diameter round a 
point midway between the nipple and the end of the sternum. This 
circle will define sufficiently, or for all practical purposes, that part of 
the heart which lies immediately behind the wall of the chest and is 
not covered by lung or pleura. 

Apex of the Heart. The apex of the heart pulsates between 
the fifth and sixth ribs, two inches below the nipple, and one inch to its 
sternal side. The place and extent, however, of the heart's impulse 
vary a little with the position of the body. Of this, anyone may con- 
vince himself by leaning forward, backward, on this side, and on that, 
at the same time feeling the heart. Inspiration and expiration also 
alter the position of the heart. In a deep inspiration it may descend 
half an inch, aud can be felt beating at the pit of the stomach. 

Valves of the Heart. The aortic valves lie behind the third 
intercostal space, close to the left side of the sternum. 

The pulmonary valves lie in front of the aortic behind the junction 
of the third costal cartilage with the sternum, on the left side. 

The tricuspid valves lie behind the middle of the sternum, about the 
level of the fourth costal cartilage. 

The mitral valves (the deepest of all), lie behind the third intercostal 
space, about one inch to the left of the sternum. 

Thus these valves are so situated that the mouth of an ordinary-sized 
stethoscope will cover a portion of them all, if placed over the sternal 



340 



SPECIAL DIAGNOSIS. 



end of the third intercostal space, on the left side. All are covered by 
a thin layer of lung; therefore we hear their action better when the 
breathing is for a moment suspended. 

Action of the Heart. The heart beats, that is, alternately con- 
tracts and dilates or relaxes, 65 to 85 times per minute in an adult. The 
wide variation in frequency is accounted for by a difference in the num- 
ber of beats in the two sexes. In females, the frequency varies from 
75 to 85; in males from 65 to 75. With each beat, blood is propelled 
throughout the vascular channels of the body and drawn from them to 
the heart chamber. The first effect is produced by the contraction of 
the heart, or the systole; the second by the relaxation, or diastole. Other 
events, as the act of respiration, contribute to the completion of the 
outflow and the inflow of blood, particularly to the latter. 

The completion of the act of contraction and the act of dilatation 
make up one revolution of cardiac action, or, as it is termed, a cycle. 
The act of contraction is known as the systolic period of the cycle ; that of 
relaxation, the diastolic period. 

Events of the Cardiac Cycle. Throughout the whole cycle several events 
occur. During the systolic period (1) the ventricles contract; (2) the 
auriculo-ventricular valves close ; (3) the blood is squeezed from the 
ventricles into the vessels, and the columns of blood in the aorta and 
pulmonary artery receive a shock from the impact of the new volume 
of blood, and an increase in their bulk. The movement of the blood 
wave from this cause and the contraction of the large vascular trunks, 
produces pulsation of the peripheral vessels and the production of the 
pulse. The contraction is immediately followed by relaxation — the 
diastole. (1) The blood columns in the aorta and in the pulmonary 
artery fall back upon the valves guarding their outlets, the aortic and 
pulmonary valves. At the same time, (2) blood pours from the veins 
into the auricles. The filling of the the latter soon occurs. (3) The 
auricular muscles contract upon the blood in the chamber, driving it 
into the ventricles. 

If a cardiac cycle is divided into tenths, the systolic period occupies 
four-tenths, the diastolic period six-tenths of the time. The systolic 
period occurs at the same time, or is synchronous with the apex beat 
and carotid pulse, and precedes by a fraction of a second the radial 
pulse. It is immediately followed by the diastolic period, which, there- 
fore, follows the carotid and radial pulse. 

Symptomatology. The symptoms of disease of the heart are due to 
the anatomical structure of the organ, to its physiological offices, and to 
the morbid process. The heart is a hollow muscular structure which 
hangs in a cavity and encloses cavities separated by valves. Both sets of 
cavities are lined by serous membrane. The serous membranes are sub- 
ject to the same diseases and present the same symptoms that take place 
in serous membranes elsewhere. Iu inflammation of the external mem- 
brane the surfaces rub together and create a sound of friction. The 
external serous cavity may also become filled with the products of 
exudation or transudation. Physical signs are produced. They are, 
however, the physical signs of increased bulk of material as deter- 
mined by inspection, palpation, and percussion, and made manifest by 



HEART, BLOOD VESSELS, AND MEDIASTINUM. 



341 



physical interference with the heart. The heart muscle is also the seat 
of processes which obtain in muscular structures. They are hyper- 
trophy and atrophy; inflammation, acute and chrouic, with overgrowth 
of connective tissue ; and degenerations. The symptoms correspond 
with symptoms of muscular hypertrophy or atrophy or of inflammation 
elsewhere, viz. : increase or weakening of the muscle, with, in the latter, 
the symptoms of the process. Increase or diminution in the power of 
the muscle is associated with corresponding change in size, which is de- 
termined by physical signs. Above all, however, such change modifies 
the functional office of the heart, so that strength or weakness of the 
muscle is shown in excess or deficiency of force of the circulation. The 
latter is more particularly an object of observation because of the conges- 
tions, dropsies, and cyanosis that ensue. 

The heart is constantly subjected to internal pressure. Dilatation of 
the cavities or a portion of the cavity (aneurism) follows previous dis- 
ease of the muscle or increase of internal pressure, and causes physical 
signs of enlargement. Degeneration of the heart muscle, nearly always 
secondary to deficiency of vascular supply, is also attended by symp- 
toms of weakness and physical signs of enlargement (dilatation), or of 
diminution in size (atrophy). When dilatation occurs the orifices of the 
cavities enlarge. The valves cannot close them. Symptoms of incom- 
petency and of blood regurgitation follow. 

The serous membrane that lines the cavities of the heart, and with 
the subserous tissues makes up the structure of the valves, is subject to 
inflammations, the symptoms of which are common to all serous in- 
flammations. The swellings and outgrowths that attend such inflam- 
mation occlude the orifices and prevent the closure of the valves. At each 
orifice obstruction to the flow of blood or improper closure of valves 
ensues. A physical interference with the heart's functions is produced, 
recognized by physical signs. The successful effort of the heart muscle 
to overcome such obstruction on the one hand (hypertrophy), or its fail- 
ure on the other (dilatation), again leads to the production of symptoms 
and signs. The serous membranes, and hence the valves, are exposed to 
causes which excite inflammation. By virtue of the position of the 
heart at the head of the circulation, the blood, infected or irritating, as in 
rheumatism and Bright's disease, constantly bathes the vulnerable struc- 
ture. For the same reason positive symptoms arise not common to serous 
membrane inflammation — that is, embolic phenomena (see Symptoms of 
Morbid Processes). 

It is the function of the heart to propel the blood. It has been 
shown how interference with the action of the muscle and with the 
flow of blood through the cavities and orifices modifies the function. 
The functional power is increased or diminished by the physical 
changes. The evidence of increased power is seen in increased force 
of muscle and increased fluid wave in the arteries (pulse). Dimin- 
ished power is shown in symptoms of lessened blood supply to parts, 
and in stagnation of the blood that is sent to the periphery. The 
former is more pronounced in cerebral anaemia, and physiological weak- 
ness of organs or the organism as a whole ; the latter, in congestions 



342 



SPECIAL DIAGNOSIS. 



The functional activity of the heart is controlled by a nervous 
mechanism, any alteration of which alters cardiac action and conse- 
quently produces symptoms. Just as with the larynx, a break in the 
cardiac mechanism may be in the centres in the medulla, the centres in 
the mnscle, or the sympathetic centres, or in the paths of the pneumo- 
gastric or sympathetic nerves to and from the heart. The rich anasto- 
mosis of these nerves exposes the heart to disturbance by reflex influ- 
ences. We should suppose such extensive innervation would invite fre- 
quent cardiac perturbation. In a measure it does take place, but fortu- 
nately, in the perfection of this mechanism, the inhibitory fibres control 
such perturbation to a large extent, so that we do not see such pronounced 
symptoms as occur in the larynx. The symptoms which point to dis- 
turbance of the cardiac mechanism are alterations in the rhythm of 
the heart. Its action may on this account be increased or diminished 
in frequency, or it may be irregular or intermittent. Such alterations 
of rhythm may be due to organic disease of the centres, notably the 
pneumogastric from apoplexy, softening, or tumor in the medulla; to 
stimulation or depression of the centres by toxic substances in the 
blood, as in uraemia, acetonsernia or autogenetic toxins or other sub- 
stances, or by nicotine or other extraneous material. The altered rhythm 
may be, and most frequently is, of reflex origin. It may be due to dis- 
ease of the nerves, as the pneumogastric or sympathetic, from pressure 
upon the nerve trunk by tumor or inflammatory growth. Palpitation is 
the most pronounced symptom of altered rhythm of which the patient is 
cognizant. When it occurs, or other arrhythmical changes are found, the 
cause must be most frequently outside of the heart, and hence more fre- 
quently sought for beyond its domain. 

While the symptoms or signs of cardiac disease are due to morbid 
processes in that organ or its membrane, it must be remembered that 
grave and persistent subjective and objective symptoms may be due to, 
or associated with, disease of contiguous structures outside of the peri- 
cardium. The symptoms are not excited through the nervous system, 
but are produced by mechanical encroachment upon the organ. They 
will be referred to in the study of objective symptoms. Care must be 
taken never to overlook the possibility of their presence. 

In the study of the symptomatology of cardiac disease the student 
must bear in mind two things : first, that the causes of the morbid pro- 
cesses and of the symptoms (pain and palpitation) may be elsewhere than 
in the heart; and second, that the ultimate object of the examination is 
to determine the muscular power of the heart. He will soon learn that 
with that power intact the functions can be performed, notwithstanding 
the presence of marked physical abnormalities. 

The recognition of disease of the heart is usually not attended by much 
difficulty, though some special lesions may involve difficulties in their de- 
termination. The non-recognition of cardiac disease is due to faults in 
the examination. The physician is too often satisfied with the recogni- 
tion of the remote process, as a congestion or functional weakness in 
some organ. Safety lies, as has often been said, in the examination of 
all the organs of the body. Often, for instance, indigestion from gastric 
catarrh is not relieved because the cause, mitral disease, is not recognized. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



343 



The Data Obtained by Observation. 

The objective signs of disease of the heart are determined by the same 
means as are employed in the detection of these signs elsewhere. In 
order to ascertain them it is necessary that the patient should be 
stripped, and a good light should fall directly on the surface as well as 
obliquely. The patient can be examined in auy position, and indeed, 
for accuracy, should be examined in all positions. This is particularly 
true when the pulse rate is taken and when auscultation is practised. The 
sounds vary frequently in different positions, to the occurrence of which 
variation some diagnostic significance is attached. It is necessary some- 
times to have the patient leau forward in order that the heart be brought 
more fully in apposition to the chest wall. 

Inspection. Examination with the eye is not confined to the heart 
alone. The reader will remember that in the account of the examination 
of the exterior and local areas, abnormal conditions were pointed out, due 
to disease of the heart. In the examination, therefore, of a case of sus- 
pected heart disease, observation is made of the general color and color 
of the local parts, as the lips and the fingers, to determine the presence 
of cyanosis, pallor, or jaundice ; of local areas, as the feet, to discover 
dropsy ; the face, to note the appearance of the countenance ; the neck, 
to note the state of the vessels; the eyes, to note their prominence; the 
thorax, to ascertain the presence of dyspnoea. 

The Pr^cordia. The prsecordia is the region of the chest which 
overlies the heart. In the study of the appearance of the prsecordia, we 
observe (1) the degree of prominence of the chest in that region; (2) the 
appearance of the interspaces ; (3) the hue of the surface ; (4) the posi- 
tion of the apex beat ; (5) the extent of the impulse. It may be un- 
duly prominent. This is common in children who have had rickets and 
some possible cardiac hypertrophy in childhood. It persists in later life. 
The bony prsecordia is prominent, irrespective of the soft tissues. The 
lower end of the sternum may project. This occurs in hypertrophy or 
dilated hypertrophy of the heart. In pericardial effusion, ribs and in- 
terspaces project. The latter are full or bulging even with the surface. 
In bulging prsecordia the distance from the middle of the sternum to the 
mid-axilla is greater on the left than on the right side. Local bulging 
may be seen at the apex in cases of aneurism of the heart. 

The prsecordia may be sunken. Old pericarditis, but more frequently 
old empyema, causes sinking in of the region. It may be a result of 
rickets or of spinal curvature. 

The interspaces. They are only retracted in pericardial adhesious ; are 
full or bulging in effusion. Only when purulent pericardial effusion is 
about to rupture, or an empyema to discharge, do we note redness or 
other change in hue of the surface of the prsecordia, not observed over 
the remainder of the thoracic surface. 

The Apex Beat. The apex, or rather that portion of the heart 
which strikes the chest wall with each systole, is evident in health in the 
fifth interspace just inside of the mid-clavicular line. It can readily be 
detected by inspection in a good light in patients with moderately thick 



344 



SPECIAL DIAGNOSIS. 



chest walls. It is due to the impulse of the ventricle against the chest 
wall just as the muscle contracts, in systole. Changes of position in 
health. It is not a fixed point in health. It moves with the move- 
ments of the body, and hence when lying on the left side it falls toward 
the left axilla as far outward as the mid-clavicular line or even beyond 
that point. It moves toward the right and downward in full inspira- 
tion, or may disappear entirely toward the completion of that act. It 
may not be observed if there is a large amount of subcutaneous fat or 
if the mammary gland intervenes. 

The Impulse. In health, in addition to observation of the posi- 
tion of the apex beat, the extent of the area of impulse is determined. 
This may be limited to the apex, or may be seen also in the third and 
fourth interspaces. 

Change in the Apex Beat. The apex beat, or the lowest point 
of impulse, may be displaced or may be absent entirely. These changes 
are due either to (a) disease outside of the pericardium, to (6) disease 
within the pericardium, or to (c) disease of the heart itself. 

Apex Displaced to the Left. This occurs from (a) Alterations 
outside of the Pericardium. The right lung may be the seat of exten- 
sive compensatory emphysema, on account of which the heart is dislo- 
cated to the left. Or the right pleura may be filled with large effusion, 
causing the same change in the heart. On the other hand, fibroid phthisis 
of the apex of the left lung, or pleural adhesions which have become 
attached to the pericardial sac, with, probably, coincident pericarditis, 
pull the heart to the left, thereby changing the position of the impulse. 
In disease of the mediastinum the heart is pushed downward and to- 
ward the left. An aneurism, an abscess, or enlarged glands in this situ- 
ation may invade the normal cardiac territory and cause its dislocation. 

In disease of the abdomen the apex is displaced. If the liver and 
spleen are enlarged, or the abdomen distended by ascites, the diaphragm 
is raised higher and the heart elevated. The apex is then seen to the 
left of the normal position, and may be one or two interspaces higher 
than natural. A common physical change in the stomach, dilatation, 
is a frequent source of dislocation of the apex. The dilatation may be 
temporary from flatulency or may be due to organic disease. 

(b) Alterations within the Pericardium. In cases of pericardial effusion, 
the apex is said to be lifted to the left, upward and outward. It is seen in 
the fourth or even as high as the third interspace, and sometimes only an 
impulse is noted in the second interspace. If used in the sense that the 
apex is the most visible portion of the heart toward the left, the above 
is true ; in other words, the edges of the left ventricle and the right ven- 
tricle, which make up the apex, are never tilted upward to the situations 
above mentioned. Instead, we undoubtedly see in pericardial effu- 
sions the pulse of the right auricle and the conus arteriosus against the 
chest wall. 

(c) Changes of the Heart Itself. The apex is displaced to the left in 
dilatation and hypertrophy of the heart. In the latter it is also dis- 
placed downward. It may be as low as the sixth or seventh interspace 
and extend as far to the left as the anterior axillary or the mid-axillary 
line. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



345 



Apex Displaced to the Right. The same causes in general 
lead to displacement of the apex beat to the right. From (a) Alterations 
outside of the pericardium. We find the heart dislocated to the right 
in left pleural effusion, and in emphysema of the left lung. We 
find, moreover, in pleural contractions and in fibroid phthisis of the 
right lung, the heart drawn to that side. Under these circumstances the 
beat in its normal position is absent, and on inspection an impulse can 
be noted either in the epigastric region, along the margin of the ribs, or 
in the second or third interspace along the right edge of the sternum. 
The impulse in the epigastric region represents the hypertrophied 
right ventricle, which usually attends the lung changes that cause dis- 
placement of the apex beat. The impulse along the right edge of the 
sternum is certainly not due to the apex beat, but to the right auricle and 
the right ventricle brought in apposition to the chest Avail by the car- 
diac dislocation. The apex, or the tip of the heart is, in all probability, 
displaced but little beyond the parasternal line. It may, theoretically 
at least, be pushed behind the sternum, (b) The apex beat is not dis- 
placed to the right in pericardial affections, (c) In disease of the heart 
itself there is no dislocation of the apex to the right. 

Apex Beat Absent. Following the same order, we find that 
the apex beat may be absent entirely in (a) disease conditions outside of 
the pericardium which intervene between the heart and the chest wall. 
Hence, in emphysema of the lungs and in compensatory emphysema of 
the left lung, the apex, or indeed any cardiac impulse, is entirely effaced. 
(6) In disease of the pericardium, the apex beat is absent when there is a 
large effusion. The absence here succeeds the dislocation to the left, and 
with it occurs effacement of the impulse in the second and third inter- 
spaces, (c) In certain diseases of the heart the apex is absent entirely. 
This is due to diminution in the size of the heart, as in the atrophy of 
chronic disease, or of old age, or to diminution in the muscle strength 
of the heart when it is fatty or flabby from dilatation. 

The Impulse. In health the impulse is limited usually to the area 
around the apex. The tissues of the thorax project with each systole. The 
area of impulse may be increased when the individual examined leans 
forward and at the end of expiration. It is larger when the chest walls 
are thin. It is lessened in opposite conditions. The area of impulse may 
be increased. The causes for increase in the extent of impulse are (a) dis- 
eases outside of the pericardium. This occurs in chronic phthisis with 
fibrous adhesions and in pleural adhesions. When the lung is drawn 
away from the surface of the heart an increase in the extent of the im- 
pulse is observed. When the heart is pushed agaiust the chest wall it 
is also observed, as in aneurism or in diseases of the mediastinum, from 
inflammation or cancer, or other mediastinal growth. In the conditions ' 
above mentioned the impulse is seen not only in the third and fourth 
interspaces, but also as high as the second, and it is not limited to 
the spaces between the sternum and parasternal lines, but may extend 
beyond the mid-clavicular line. (6) From disease of the pericardium the 
area of impulse is increased if moderate effusion is present. It will 
be seen as a diffuse wave occupying the second, third, and fourth inter- 
spaces. It is also increased in pericardial adhesions without increase in 



346 



SPECIAL DIAGNOSIS. 



strength, (c) Diseases of the heart. The disease must cause enlarge- 
ment, and hence must be either hypertrophy or dilatation. The extent 
of impulse varies. In hypertrophy the impulse may be communicated 
to the sternum, so that the lower part heaves with each contraction. It 
falls below the fifth interspace and toward the left, particularly if the 
left ventricle is the seat of the enlargement. If the right ventricle is 
hypertrophied the impulse is very marked in the sixth and seventh 
interspaces near the termination of the cartilages, or in the epigastrium 
along the border of the ribs of the left side. Sometimes, when asso- 
ciated with and displaced by lung disease, it is seen to the right of the 
xiphoid cartilage. 

Impulse Absent. The same reasons that cause absence of the 
apex beat are sufficient to cause absence of impulse, and they need not 
be again repeated. 

Retraction of Interspaces. In place of swelling or projection 
of the interspace or interspaces rhythmical retraction sometimes takes 
place. This retraction may be limited to the apex or may occur in each 
interspace over the precordial region. It may occur with the systole 
or with the diastole. It is of some diagnostic significance when it is 
systolic in time, and is said to indicate adhesions of the pericardium, 
traction upon which by the systole of the heart causes the interspaces to 
be drawn in. The adhesions may prevent the lung overlapping the 
heart, so that the area of impulse and position of apex are not changed 
by full inspiration. (See Pericarditis.) 

New Causes of Impulse. In addition to uniform increase or dimi- 
nution in the impulse, new areas of impulse, not due to the extension of 
the normal impulse, arise from enlargement of one of the cardiac 
chambers or from disease of the bloodvessels. When seen in the 
second or third interspace on the left the area of impulse is due to hyper- 
trophy and dilatation of the right ventricle, as in mitral obstruction ; or 
it may be due to retraction of the lung in that region. If the impulse 
is noted in the course of the aorta or adjacent thereto it is indicative of 
aneurism. In the second or third left, or first or second right, interspace, 
the physical signs of this affection determined by palpation, auscultation 
and percussion indicate the nature of the pulsation. 

Palpation. Palpation confirms inspection as to the shape of 
the prsecordia, the condition of the intercostal spaces, the position 
of the apex beat, and the extent of the impulse. In addition we learn 
by palpation of the character and strength of the impulse, and note the 
presence or absence of valve shock and of thrills. By palpation also 
oedema of the surface is recognized and fluctuation may be detected. 
In a normal chest with moderate walls a slightly prolonged, moderately 
strong shock is transmitted to the hand when placed over the praecor- 
dia. It is synchronous with the cardiac and precedes the radial pulse. 
It is therefore systolic in time. It is stronger when the patient leans 
forward or exhales freely, removing the lung from the surface, or in 
thin chest walls it is weaker in opposite conditions. 

Character and Strength of Impulse. A.. The impulse may be stronger 
than in health. 1. Increased action. It must not be forgotten that in 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



347 



the violent action of the heart that attends palpitation and the increased 
action in the early stages of fevers or of inflammation, the force of the 
cardiac impulse is much increased. 2. Disease, (a) On account of disease 
outside of the heart, by reason of which the heart may be brought 
nearer the hand. Increased force is also observed when the patient leans 
forward. If the lung is drawn away by adhesions or phthisical con- 
traction, or the heart pushed against the surface of the chest by medias- 
tinal growths, the force of the impulse is increased. (6) In pericardial 
adhesions the heart is held more firmly against the wall and may give 
the appearance of strength to the impulse, (c) True increase in force 
of the impulse is seen in disease of the heart itself. When the organ 
is hypertrophied or the seat of dilated hypertrophy, the force of the 
impulse is increased, sometimes for the patient to an almost unbearable 
degree. Uplifting of the precordial area or even the lower half of the 
anterior part of the chest is seen. The hand or the head laid over the 
heart is forcibly lifted with each systolic contraction. This great force 
is most pronounced in the enormous hypertrophy that occurs in cases 
of aortic obstruction. It is the impulse and force of the so-called cor 
bovinum. In dilatation the impulse is diffused and wavy. 

B The strength may be lessened or the impulse not felt at all. This 
occurs from causes which diminish the impulse or cause it and the apex 
beat to be absent entirely, as when material intervenes between the heart 
and the chest wall, or the heart is weakened by disease. Hence (a) in 
emphysema of the lung; (6) in pericardial effusions ; (c) in fatty heart, or 
myocarditis, in dilatation and simple weakness of the heart, the strength 
of impulse is lessened. 

Valve Shock. The shock of the closure of the valves can be felt 
by the hand when placed evenly over the prsecordia. The shock from the 
pulmonary and aortic valves is best transmitted. It is felt most distinctly 
in persons with thin chest walls and in cases in which there is heightened 
tension either in the aorta or pulmonary artery. The shock follows the 
impulse. It may be localized more precisely by the finger-tips in the 
third or fourth interspace along the left edge of the sternum. The 
shock of the auricular ventricular flaps is also transmitted. The shock 
is synchronous with the first sound. It is felt in the left fourth inter- 
space near to the sternum, sometimes over it. It is due to dilatation of 
the heart and is more readily felt in thin-chested persons. 

Thrills. A thrill is produced when the blood is thrown into vibra- 
tions by passing over a rough surface. It may be created with the 
systole or during the diastole. It can only be created at the time blood 
is passing through the orifices. 1. The most common seat of the thrill 
is at the apex. If the hand is placed in close apposition to the surface 
of the chest at this point a vibration or tremor is transmitted to it in 
most cases of mitral obstruction. The blood is passing from the auricle 
to the ventricle ; as this takes place before the systole the thrill is felt 
at that time and hence before the impulse or carotid pulse. It is pre- 
systolic in time. It is sometimes difficult, however, to separate it from 
the impulse. Its characters cannot well be described. The hesitating, 
jogging manner of the vibrations or the thrill is clearly transmitted to 
the hand. 2. The next most frequent seat of thrill is at the second 



348 



SPECIAL DIAGNOSIS. 



costal cartilage on the right. Here the thrill or vibration is systolic in 
time and is caused by obstruction at the aortic orifice. It may be felt 
away from the heart, in the aorta, or in the carotids. The aortic valves 
are thickened, contracted, and stiffened by a sclerotic endocarditis or the 
orifice occluded by valvulitis. 3. Sometimes a thrill is felt at the anex 
with the systole — first sound. This occurs rarely, but must not be con- 
founded with the before-tir»t-sound thrill. It is never so distinct, and 
is not made up of a series of vibrations. It is due to regurgitation at 
the mitral orifice. 4. Rarely a thrill is felt at the second costal cartil- 
age on the right, with the second sound. It may be felt along the course 
of the sternum also, and is due to regurgitation through the aortic orifice. 
The systolic thrill must not be confounded with the thrill elicited over 
the aorta or at the aortic cartilage due to aneurism. 5. At the second 
costal cartilage at the left a thrill is sometimes felt. It is systolic in 
time and is not transmitted. It is due to obstruction at the pulmonary 
orifice. 6. At the lower portion of the sternum a thrill systolic in time 
is also felt, due to tricuspid regurgitation. Care must be taken not to 
confuse the above-mentioned thrills with those due to aneurism. (See 
Aneurism.) 

Pericardial Friction. In addition to the thrills a friction or to- 
and-fro rubbing is transmitted to the hand in cases of pericarditis in 
the first stage. The friction is felt over the heart region, but is pro- 
nounced in the third or fourth interspace. It may be detected on slight 
pressure or not revealed unless firm pressure with the tips of the fingers 
in the interspaces is used. 

It is important to remember that the position of the patient 
modifies or weakens the intensity of thrill or friction. When the 
patient is lying down it may not be felt. The upright posture or lean- 
ing forward makes it evident, and hence the patient should be instructed 
to assume this position in the examination if possible. 

Diagnostic Significance. Of the above-mentioned thrills the one 
due to mitral obstruction is more frequently present in that valve lesion 
than thrills in other lesions. Indeed, it is pathognomonic of the 
disease. 

Percussion. By means of percussion the form and size of the 
heart and the area of cardiac dulness are determined. The lungs over- 
lap the heart and in inspiration allow a small area to be in apposition 
with the chest wall. To determine the size of the heart, both superficial, 
or light, and deep, or strong, percussion must be employed. By the 
former we determine the area of superficial or absolute cardiac dulness ; 
by the latter, the area of deep cardiac dulness. 

1. The Area of Superficial or Absolute Cardiac Dulness. 
— It is the area not covered by the lung at the time of inspiration. The 
percussion force employed must be light, so as to elicit the resonance of the 
extreme thin edge of the lung. The area extends from the fourth to the 
sixth costal cartilages. The right border may be defined by a line drawn 
between two points fixed on the median line of the sternum opposite 
the cartilages above indicated. Join the upper extremity with a point 
at the position of the apex beat. It marks the upper and left border. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



349 



A line joining the apex and the point on the median line of the sternum 
opposite the sixth costal cartilage and above the ensiform cartilage, 
marks the lower border. 

Fig. 59. 




Showing percussion of the heart and liver, the degree of shading indicating the degree of dul- 
ness. The margin of the lung is indicated by the dotted lines. The liver is enlarged. (Gibson 
and Russell.) 

Method. The right border is determined by percussing from with- 
out inward to the median line. Always begin to percuss far enough 
from the sternal edge to get the clear pulmonary note. To insure uni- 
formity, select a definite area in all cases from which to start. Apply 
the finger vertically at first. The right border may correspond with a 
line outside of or along the right edge of the sternum, the median line or 
the left edge of the sternum, or even beyond the latter. After the edge 
of the modified resonance is reached, percuss with the finger parallel 
with the ribs, as described by Gibson, to control the result previously 
secured, and as each interspace is percussed to determine the upper limit 
of liver dulness and the triangle between the liver and heart. 

The left edge is determined by percussing in vertical lines from a 
point near the axilla toward the heart. Opposite the second and third 
interspaces on the right side the aorta, and on the left the pulmonary 
artery, can be defined. The student should acquire the habit of pro- 
ceeding from definite fixed positions toward the heart, and to observe 
the changes during inspiration and expiration. The lower border and 
rounded apex cannot be defined if the stomach contains food or fluid. 
It is triangular in shape, with the apex pointing downward. 

Changes in Size. The superficial area of dulness or absolute dulness 
is increased in pericardial effusion or enlargement of the heart. It is 



350 



SPECIAL DIAGNOSIS. 



replaced by resonance in emphysema, and hence absent entirely, as the 
lung overlaps or completely covers the heart. It is absent when the 
heart is drawn under the lungs by adhesions, and when there is air 
in the pleural or pericardial sac. 

Deep Cardiac Dulness. It is of the greatest importance to ascer- 
tain the deep or relative area of cardiac dulness. The percussion must 
be strong. The best method by, which it can be accurately determined, 
is that advised by Gibson and Russell. Their directions are as follows : 
Begin in the upper left interspaces sufficiently far out from the sternum 
to secure pulmonary resonance. For instance, in the second interspace 
begin in the mid-clavicular line and percuss strongly. As soon as a slight 
alteration in that sound is noted the point is indicated by a mark. The 
second or third and succeeding interspaces are percussed in like manner, 
bearing in mind that the percussion must begin farther out in each inter- 
space in order to get pure resonance. As dulness is secured in each space 
a mark is made. This is continued to the apex if that is visible, or to 
the base of the chest. By joining the marks in each interspace with 
the line at the base of the heart the left border of cardiac dulness can 
be fixed. The authors well point out that in this way the true apex of 
the heart is found, enabling auscultation to be conducted more accurately. 
The right edge of the vessels and of the heart is defined in the same 
way. The difference in the sound in passing from the lung to the heart 
is not so distinct along the right border as the left. The authors include 
the dulness which is due to the vessels at the base of the heart, and 
hence begin percussion in the higher interspaces. This is proper, 
because it is impossible to delimit the two. The dulness of the vessels 
is not so marked, however, and may be indicated by simple change in 
pitch in the percussion note. The lower border of cardiac dulness is 
ascertained with difficulty, because of its close apposition with the liver. 
At times there is a difference in the character of the dulness between 
the two organs. It can be well made out by stethoscopic percussion. 
This may not be so pronounced as we pass from the heart to the liver 
in the median and parasternal lines. Toward the apex the difference 
is more apparent. The writer has been teaching and practising this 
method of percussion ever since it was proposed by the authors, and 
can testify to its accuracy in clinical studies and the ease with which 
students are able to practise it. 

Deep Dulness Increased. The increase in the area of relative dulness 
in all directions occurs in hypertrophy of the heart and in pericardial 
effusions. The increase in width above the base of the heart occurs in 
dilatation and aneurism of the aorta. Change in the position of the 
heart, a general idea of which is previously obtained by inspection and 
palpation, always changes the shape and extent of the dulness. The 
heart should be accurately delimited when displacements have taken 
place. 

Increase or Extension of Deep Dulness Upward or to the Right or Left. 
In addition to general increase in cardiac dulness, one of the boundaries or 
a portion of the boundary may be increased or extended beyond the nor- 
mal line. (1) Thus the area of dulness may extend upward. It may 
be followed by extension of the right and left boundaries. The relative 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



351 



area of dulDess is abolished. The change from pulmonary resonance 
to dulness is decided. The heart dulness becomes pyramidal or pyri- 
form in shape. It is due to effusion in the pericardium. (2) Increase 
in dulness to the left occurs in enlargement of the heart from hypertrophy 
or dilatation. If the dulness extends outward to the left and retains the 
triangular shape, with the apex pointed, it is due to hypertrophy of the 
left ventricle. If, on the other hand, it becomes quadrilateral in shape, 
with the apex rounded, it is due to dilatation of the left ventricle. 
The results of palpation and inspection aid in proving the presence of 
one or the other of the two conditions. (3) The area of dulness 
extends to the right. It is due to hypertrophy and dilatation of the 
right auricle and ventricle. When the auricle, the right edge is 
extended beyond the normal in the third and fourth, or as high as the 
second, interspace. With this increase in dulness there is also seen an 
epigastric impulse, venous turgescence and pulsation of the veins of the 
neck or of the liver. (4) Increase in the area of dulness over the 
bloodvessels is usually due to aneurism. It may be general, as in dilata- 
tion, or more marked in local situations. Extension of the dulness 
outward or upward from the normal line may be found at the 
right of the sternum, or over the first bone of the sternum, or to the 
left just above the cardiac area. In the latter the dulness is an extension 
upward of the normal area of cardiac dulness with rounding of the 
area affected. The aneurism is situated in this case at the commence- 
ment of the aorta. 

Pleximetric Percussion. For more accurate cardiac percussion, Sansom 
recommends the use of a pleximeter of his design by which delicate shades 
in dulness can be readily detected by the ear. The pleximeter is a thin, 
flat, oblong plate one inch by half an inch, which has on its upper surface 
a column rising from the middle, one and a half inches in height, which is 
surmounted by a plate three-fourths to three-eighths of an inch set 
parallel with the lower plate. The instrument is held by the fore- and 
middle fingers of the hand, applied on each side of the vertical column, 
the sensitive tips of the fingers resting on the upper surface of the larger 
horizontal plate. The lower surface of this latter is applied closely to 
the wall of the chest, and percussion with one or two fingers of the 
right hand with an even and not too forcible stroke from the wrist is 
made upon the upper plate. Of course vibrations are created by the 
blow. They are transmitted to the ear and also appreciated by the digital 
sense of touch, both of which aid in the determination of the nature of 
the sound produced. 

Method. The pleximeter is placed with its long diameter parallel 
with the sternum about midway from the axilla to the right sternal 
border. Percussion is made upon the summit of the column by one or 
two fingers. As this is performed the pleximeter is moved, always in 
parallel lines, nearer and nearer to the sternum. A line is reached 
where the vibrations are modified. Incline the pleximeter so that the 
vibrations come from its left edge. This edge, or line, is practically 
the line of demarcation of the dulness and should be indicated by an aniline 
pencil. It corresponds to the outline of the right border of the heart. 
(See Fig. 59.) The process must be repeated at higher and lower levels 



352 



SPECIAL DIAGNOSIS. 



until the entire right area of cardiac or aortic dulness is ascertained. 
In passing, it may be stated that percussing from above downward with 
the long diameter of the pleximeter horizontal instead of vertical, leads 
to the upper limit of the liver as indicated by modified vibrations. 
About the fifth right intercostal space a short curved line is thus made 
out along the right edge of the sternum which indicates the outline of 
the right auricle at the point where it joins the liver dulness. Above 
this, as far as the second rib, the line indicates the outline of the right 
border of the auricle and the aorta. The outline of the auricle may 
be in the mid-sternum ; of the aorta, at the right edge. In percussing 
the left side of the chest the same method is adopted. Begin at the 
level of the second rib two or three inches beyond the left edge of the 
sternum, and move to the right. Join the lines of modified vibrations, 
and in this manner the left border of cardiac and aortic dulness is 
secured. The outline of the apex of the heart is readily mapped out. 
Over the tympanitic stomach light percussion is necessary. To narrow 
the area of percussion about the apex the percussion may be performed 
on the larger plate while the smaller is applied to the chest. The 
vibrations over the liver and over the right ventricle are difficult to 
distinguish, although sometimes so different that demarcation of the 
border of the ventricle presents no difficulty. Between the apex of the 
left ventricle and the left lobe of the liver the space is easily marked out. 
A correct outline of the heart and of the vessels is thus obtained. The 
upper limit of dulness is formed by the right auricle, the aorta and the 
pulmonary artery. Any bulging or undue expansion is due to aneurism, 
or aneurismal dilatation of the aorta. The space between the apex and 
the left lobe of the liver defines the lower border. Sausom well points 
out that by his method of percussion the following absolute data can be 
obtained : A projection to the right of the area of the upper part over 
the second and third interspaces, points to aneurism of the aorta or of the 
innominate artery. It may be traced to the left side of the sternum on 
account of saccular dilatation of the aorta. If the dulness at the upper 
part extends greatly to the left an increase in size of the pulmonary 
artery may be suspected. Along the mid-sternal regiou, extension 
beyond the right side joining the line indicating the upper border of the 
liver indicates distended inferior cava. This distention occurs in right- 
sided dilatation of the heart, and the dulness may also be due to dilata- 
tion of the adjoining auricle. The outline of dulness obtained over the 
apex of the heart if pointed indicates hypertrophy ; a more rounded 
outline shows dilatation. In uncomplicated hypertrophy the line of the 
right ventricle forms a much less obtuse angle with the liver dulness 
than in dilatation. Of great diagnostic value is the diminution of the 
area of dulness from atrophy of the heart as observed in wasting, as in 
cancer and in tuberculosis; it may also be observed in typhoid fever. 
In the above-mentioned conditions it is a bad prognostic sign. 

Adjacent Dulness. Care must be taken not to confound the dulness 
of pleural effusion or consolidated lung with the cardiac dulness. 

Repercussion. Modification of the vibrations felt by the fingers on 
the pleximeter, as pointed out by Sansom, may indicate an abnormal 
change in physical condition not attained in any other way. It 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



353 



is to be remembered that over the kings the vibrations are in excess ; 
over solid structure they are modified or lessened. Now, change from 
vibrations to absence of vibrations may be gradual or abrupt. San- 
som determines as follows by repercussion after the heart has been 
outlined in the above-mentioned manner. In percussing from the 
lung and the heart area, if the modified vibrations occur abruptly, it is 
very probable that there is pericarditis with effusion or thickened peri- 
cardium. Or if, on percussing from above downward, there is effusion 
in the pericardial sac, no vibrations are to be elicited over the area 
delimited. That is, the absence of vibrations is noted over the whole 
area ; whereas, in ordinary conditions, when the pericardium is unaf- 
fected, in percussing from above downward over the area which had 
been delimited on the right and left sides respectively, a line will be 
reached where the vibrations become modified. This line commences a 
little above the ensiform cartilage and inclines tow T ard the left border of 
the cardiac dulness at the level of the fourth rib and the third interspace. 
Vibrations are more marked above than below the line. The line at which 
the lessened vibrations begin points out the commencement of the thick 
wall of the ventricles; the portion above (more vibratory) indicates the 
position of the right auricle and vessels. If plessimetric percussion is 
employed, areas of superficial and deep dulness need not be estimated. 

Apex Beat Whichever method of percussion is employed it will 
be often observed that the spot noted by inspection and palpation 
as the apex beat is far outside of the left border of cardiac dulness. 
In hypertrophy of the left ventricle it may be a considerable distance 
to the left. In dilatation the difference is not so marked. The percus- 
sion lines are made when the heart is away from the chest, and hence 
are within the systolic apex beat. 

Method of Graphic Record. We are indebted to Sansom and Ewart 
for a method of record of the outlines of the areas of dulness and the 
position of the apex beat and other pulsations, which is of great value 
for class demonstration and for permanent records in order to compare 
with other records taken from time to time. The points of pulsation 
and border lines of dulness are marked by a dermatographic pencil. 
Various colors may be used in order to indicate the different data. The 
landmarks, etc., are outlined by a camePs-hair pencil dipped in olive 
oil. The episternal notch, the clavicles, the intercostal spaces, the 
ensiform cartilage and nipples, etc., the percussion outlines, and other 
recorded marks, are passed over with the pencil. A sheet of tissue 
paper, or of copying paper, is then gently pressed over the whole, so that 
the oil-marks are imprinted. After the paper is removed, the oil out- 
line is colored by the dermatographic pencil, and a permanent record is 
preserved. By this plan of recording a maximum of precision is attained. 
Outlines can be measured and positions defined by mathematical data, 
The name of the patient, the date of observation, with a brief history of 
the case, should be attached to the chart, If the colored pencil-mark- 
ings on the patient's chest are objectionable, the outline may be made 
with the colorless oil-pencil at the various steps of the examination. 
After they are transmitted to the paper they may be made more graphic 
by the colored pencils. 

23 



354 



SPECIAL DIAGNOSIS. 



As an objection to the use of the above for comparative records, 
Ewart has shown that after long intervals the size of the chest and 
abdomen are apt to alter from various circumstances — growth, muscular 
development, habit of sitting, etc. He points out the advisability of 
using a fixed structure for reference, as the sternum, which is invari- 
able. By utilizing its edges we have unalterable landmarks. 

Sense of Resistance. Ebstein delimits the heart by the sense of 
resistance, change in size being noted by increase or diminution of the 
area, which in health gives a sense of resistance to the percussing 
finger. 

Auscultation. Method. Either method of auscultation may be em- 
ployed in order to secure data derived from the sense of hearing. The 
mediate, however, is preferable because it is essential to localize the 
sounds that are heard. By the immediate method we may form a gene- 
ral notion as to the condition of the heart sounds, but for the above- 
mentioned reason, and because if the double stethoscope is used we can 
also inspect the cardiac area, auscultation by the mediate method is pre- 
ferable. The patient should be in a comfortable position. The muscles 
should not be strained. The general direction for performing ausculta- 
tion must be followed out. Before it is commenced the observer has 
determined, if possible, the presence of the apex beat. If not, the first 
step must be to find the radial or carotid pulse. By this means the 
events of the cardiac cycle are ascertained. The systole is synchronous 
with the apex beat, or carotid pulse. It occurs just before the radial 
pulse. 

The Sounds in Health. The stethoscope is placed over the base of the 
heart at about the fourth interspace, with the finger on the apex or the 
radial pulse ; a sound will be noted corresponding with the systole or 
apex beat, followed almost immediately by another sound and then a 
period of silence. The sound that attends the systole is known as the 
systolic, or first sound. The sound that follows is known as the dia- 
stolic, or second sound. The sounds and silence mark the completion of 
a cardiac cycle as far as the ear is concerned. A definite relationship 
in time exists in the cardiac cycle. If the entire cycle occupies one 
second of time and is divided into tenths, the sound that attends the 
systole will occupy four-tenths, the interval between this first sound 
and the one in diastole, one-tenth ; the sound that attends the diastole, 
two-tenths; and the silence, three-tenths of the entire period. By 
the above method, the first essential in auscultation is learned, viz., 
to associate apex with pulse beat and the relation of the sounds 
to the sounds of a cardiac cycle. In this manner the rhythm of the 
heart is ascertained and the character of the sounds is then studied. The 
character depends upon the cause, the points of origin and direction of 
conduction. Cause. Four sounds are created during a cycle, one at 
each valve. The sounds created with the systole (systolic sound) are 
due to contraction of the right ventricle and closure of the tricuspid 
valve ; and on the opposite side, of the left ventricle and the mitral 
valve. The rush of blood aloug the course of the vessels and the shock 
of the heart may contribute somewhat to the systolic sound. The 
sounds heard in the beginning of the diastole are due to the closure of 



HEART, BLOODVESSELS, AND MEDIASTINUM. 855 



the aortic and pulmonary valves. They are due to the tension pro- 
duced on the valves as the respective arteries contract upon the columns 
of blood. The closures of the valves make up most, if not all, of the 
sounds. To review : two sounds occur with the systole, one from 
closure of the mitral, another from closure of the tricuspid valve; two 
with the diastole from closure of the aortic and pulmonary valves re- 
spectively. Modifications in the intensity of the sound are due to 
changes in the tension of the valve curtains, and are dependent upon 
the muscle. If it is strong, the valves are made more teuse. Experi- 
ment and the results of disease have aided in proving these pointe. 



Fig. 60. 




Areas of cardiac murmurs (Gairdner for the areas; and Luschka for the anatomy). The out- 
lines of organs, which are partially invisible in the dissection, are indicated by very fine dotted 
lines ; while the areas of propagation of valvular murmurs, as described in the text, have been 
roughly marked by additional much coarser and more visible dotted lines— the character of the 
dots being different in each of the four areas. A capital letter marks each area, viz. : A, the circle 
of mitral murmurs corresponding with the left apex ; B, the irregular space indicating the ordi- 
nary limits of diffusion of aortic murmurs, corresponding mainly with the whole sternum, and 
extending into the neck along the course of the arteries ; C, the broad and somewhat diffused 
area occupied by tricuspid murmurs, and corresponding generally with the right ventricle ; D, 
the circumscribed circular area over which pulmonic murmurs are commonly heard loudest. 

Reference letters : r. au. = right auricle ; a. o. = arch of aorta ; v. i. =the two innominate veins ; 
v. c. = vena cava descendens ; p. = pulmonary artery; 1. au. = left auricle ; 1. v. =left ventricle ; 
r. v. = right ventricle. (Finlayson.) 

Seat of origin and transmission. The sounds produced by the 
closure of the valves are developed, as the topography of the heart 



356 



SPECIAL DIAGNOSIS. 



shows, quite near to each other, but by the conduction of sound they 
are transmitted in particular directions, and heard loudest in definite 
areas on the chest, The systolic or first sounds. The mitral area. The 
sound produced by the closure of the mitral valve created at the fourth 
interspace near the sternum is transmitted to the surface of the chest 
by the thickened left ventricle, and hence is heard loudest where that 
is nearest the chest, namely, the apex. The tricuspid area. The sound 
produced by the closure of the tricuspid valve is transmitted by the 
right ventricle and is heard loudest over the lower portion of the 
sternum. Thus it is seen that the systolic, or first sounds, are heard 
loudesfr at the lower portion of the heart. The diastolic or second 
sounds. Two sounds are created. The valves at which they are 
produced are also in close proximity. To distinguish the two sounds 
it is necessary to auscult over areas to which they are transmitted. 
These areas have been definitely ascertained by the same means as those 
employed when the other valve was analyzed. They are known as 
the aortic and pulmonary area. 

The Aortic Area. The sound produced at the aortic valve by its 
closure is heard loudest at the second costal cartilage on the right, 
because the aorta which conducts the sound is nearest the surface of the 
chest at this point. This cartilage is known as the aortic cartilage. 

The Pulmonary Area. The sound produced by the closure of the 
pulmonary valve is conducted to the left and heard loudest in the second 
interspace near the left edge of the sternum. It is seen that the dia- 
stolic sounds are heard at the base of the heart. (See Fig. 60.) 

Character of the Sounds. The systolic sounds are prolonged, 
somewhat dull in character, low in pitch, and resemble the sound pro- 
duced by the pronunciation of the syllable u ubb." The diastolic sounds 
are short, sharp, and quick and resemble the sound produced by the 
pronunciation of the syllable " dupp." The syllables ubb, dupp indicate 
the character of the sounds in health. 

Differentiation. To distinguish the sounds produced by the 
auriculo- ventricular valves (systolic) from the valve sounds produced 
at the vessels (diastolic), we observe, first, the time ; second, their rela- 
tion to the periods of silence in the cardiac cycle ; third, the character 
of the sound ; and fourth, the position at which they are heard 
loudest. 

1. The Time. The first sounds are systolic in time. They occur at the 
same time as, and correspond with, the apex beat and carotid pulse, and 
they precede slightly the radial pulse. They are followed by a short 
silence. The second sounds are diastolic and follow the pulse. 

2. Relation to the Period of Silence. The second sounds practically 
follow the first and precede the long silence. 

3. The Character. The first sounds are low in pitch, dull and pro- 
longed ; the second sounds are high in pitch, short and sharp. 

4. Situation. The first sounds are heard loudest at the apex of the 
heart and the base of the sternum and are transmitted toward the axillse. 
They may be heard all over the cardiac area, but the position of maxi- 
mum intensity is in the lower portion and toward the left, The second 
sounds are loudest at the base of the heart. They may be propagated 



HEART, BLOODVESSELS, AND 



MEDIASTINUM. 



357 



beyond the prsecordia toward the neck and be heard loudest in the 
vessels of the neck. 

Differentiation of Each Sound. 1. Mitral first or systolic 
sound, heard loudest at the apex, inward to the parasternal line, upward 
to the third interspace. 2. Tricuspid first or systolic sound, heard 
loudest at the lower part of the sternum and toward the left to the para- 
sternal line as high as the third rib. 3. Aortic second or diastolic 
sound, heard loudest at the aortic cartilage, propagated into the vessels 
and also heard at and outside of the apex beat. 4. Pulmonary second 
or diastolic sound, localized to the second interspace and the third rib. 

Modifications of the Sounds. All of the sounds or one or 
more of the four sounds may be increased or diminished in intensity or 
accentuation. 

All Sounds Increased, a. Causes outside of the pericardium. (1) 
Anything which brings the heart closer to the ear of the observer. 
Thus, in patients with thin chest walls, when the heart is pushed to the 
surface of the chest (mediastinal tumor) or the lung removed (pleural 
contraction). (2) Anything which conducts the sounds, as consolidated 
lung in the vicinity, or a pneumothorax, or pulmonary cavities ; the 
sound is intensified, b. Affections of the pericardium, as pericardial 
adhesions, c. Conditions of the heart. (1) Hypertrophy. (2) Over- 
action, as in palpitation, ansemia, fevers, exophthalmic goitre. 

Weakness of All Sounds, a. Conditions outside of the pericardium. 
1. General exhaustion. 2. Thick chest walls, large mammary gland. 
3. Emphysema of the lungs overlapping the heart, b. Conditions in 
the pericardium, as fluid or air in the pericardial sac. c. Conditions 
of the heart. Atrophy ; myocarditis ; some cases of dilatation. 

In short, loudness of all the sounds occurs from (a) conditions outside 
of the heart : heart nearer chest wall, consolidation of lungs, cavities ; 
(b) conditions of the heart itself : hypertrophy ; overaction. Weakness 
of the sound occurs from — (a) conditions outside of the heart : thick 
chest walls, emphysema, general exhaustion ; (6) affections of the peri- 
cardium : effusions; (c) affections of the heart: atrophy; dilatation; 
myocarditis. 

Changes of Individual Sounds. The above applies to all the 
sounds. Increase or diminution of the systolic or the diastolic sounds, 
or of any one of the four sounds, may be present. 

Increase in Loudness of the First Sound. Increased loudness of the 
first sound is noted when the muscle is hypertrophied, and the tension 
on the valves thereby increased. In hypertrophy of the left ventricle 
the increase is most marked. The sound is duller and has a prolongation 
which is very characteristic. In hypertrophy of the right ventricle 
the sound is dull and prolonged over the sternum, but not to the degree 
of the left when it is hypertrophied. 

Increase in Loudness of the Diastolic Sound. Either of the second, 
or diastolic sounds, may be increased in loudness or accentuated. 

Accentuation of the Aortic Diastolic Sound. Anything which causes 
increased tension in the aortic circulation, and hence increased contrac- 
tion of the aorta, will increase the intensity or accentuation of the second 
sound. In hypertrophy of the heart the aortic sound is accentuated 



358 



SPECIAL DIAGNOSIS. 



because there is corresponding increased contraction of the aorta following 
the forcible propulsion of the blood from the ventricle. Increase in 
arterial tension is due to iucreased contraction of the aorta when there 
is peripheral resistance to the outflow of blood. It is associated with 
the following conditions which cause accentuation of the second sound : 
Atheroma of the aorta, or of the arteries in general, is attended by 
increased accentuation of the second sound when there is at the same 
time heightened arterial tension. It is present in aneurism of the 
aorta. It is notable in disease of the kidneys, and particularly in 
that form in which there are also general arterial changes, namely, 
chronic interstitial nephritis. It is true that a portion of the accentua- 
tion may be due to the hypertrophy of the heart which exists. 

Accentuation of the aortic second sound occurs independently of per- 
manent change in the arteries. If for any reason there is spasm of the 
peripheral capillaries, as from a chill, from epilepsy, from nervousness 
due to hysteria, tension in the arteries is heightened, and hence the 
second sound accentuated. It is seen that accentuation of the second 
sound is therefore a marked index of the state of the vascular system 
in general ; it is not only an evidence of disease of the heart. In 
certain fevers and in states of the blood in which the vasomotor nerves 
are irritated, causing peripheral contraction, as in scarlatina, accentua- 
tion of the second sound follows. This arises often before the develop- 
ment of local inflammatory diseases due to the same cause, as nephritis 
in scarlatina. The occurrence of this complication may be suspected 
when accentuation of the aortic second sound is heard. 

Accentuation of the Pulmonary Diastolic, or Second Sound. This 
is due to the same physical condition which causes accentuation of 
the aortic second sound. Anything which heightens the tension in 
the pulmonary artery will cause increased loudness. In health the 
pulmonary second sound is not so loud as the corresponding sound of 
the aorta. If, therefore, we find in the second or the third left inter- 
space the sound as loud as an aortic sound, or louder, it can be said 
that the pulmonary second sound is accentuated. It is due: (1) To 
any condition which causes congestion within the lungs, the right ven- 
tricle being at the same time of normal or increased strength. It is 
heard in the early stages of pneumonia, and if the course of the disease 
continues favorable may remain accentuated to the end. If, on the 
other hand, the circulation is embarrassed, and the right heart is failing, 
it will become fainter, and may be scarcely recognizable. Such change 
in the sound accompanies increase of respiratory distress, and indicates 
that the right heart is becoming exhausted. It is a sign of prognostic 
omen in acute pulmonary disease. If the case is unfavorable, the signs 
of right-sided dilatation will subsequently occur. (2) It occurs in 
emphysema of the lungs. Notwithstanding the covering of the heart 
by the lung, the sound can be heard, and may be the only one of the 
four sounds which is distinguished. (3) In valvular disease of the 
heart seated at the mitral orifice, accentuation of the pulmonary second 
sound, due to increased tension in the artery, is heard. In mitral 
obstruction the blood is retained in the auricle and pulmonary veins, 
causing a pressure, which is exerted against the force of the right 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



359 



ventricle. Increased tension in the pulmonary artery is a result, with 
exaggerated strain upon the valves. In mitral regurgitation, with the 
systole the blood is thrown back into the auricle, and consequently 
meets with blood coming from the lungs. This in time increases the 
amount of blood and of blood pressure in the pulmonary artery. A 
heightened tension results. 

Skoda pointed out the significance of this association. Sometimes in 
doubtful cases, either in the preseuce or absence of a murmur at the 
mitral orifice, the occurrence of this sign makes it more than probable. 

Diminished Accentuation or Weakness of the Aortic Sound. This is 
an indication of cardiac weakness, and is liable to ensue in the course 
of fevers when exhaustion takes place. It is a sign of myocarditis and 
of degeneration of the muscular walls of the heart. Under these cir- 
cumstances the systole of the ventricles is also weakened. 

Feebleness of the aortic second sound, with a strong systole of the 
ventricle, occurs when the aortic leaflets are swollen or enlarged and 
thickened. This condition of the valves is due to atheroma, and is in 
all probability associated with atheroma of adjacent vessels, as the coro- 
nary arteries. It is, therefore, a sign of serious import. 

Diminished Accentuation or Feebleness of the Pulmonary Sound. 
This is of importance to note in the course of valvular disease of the 
heart, providing previous accentuation has been observed. If the 
marked loudness gives way to feebleness there is strong probability 
that the right heart is undergoing dilatation with regurgitation at the 
tricuspid orifice. While accentuation of the pulmonary second in val- 
vular disease is of good omen, enfeeblement of the sound is of bad 
prognostic omen, indicating weakness of the right ventricle. 

Feebleness of the Mitral Sound. Feebleness of the mitral sound 
observed at the apex of the heart may be an indication of weakness 
of the muscle from dilatation, atrophy or myocarditis. It must be 
remembered, however, that weakness of the ventricle is not attended by 
enfeeblement of sound, but that when the right or left ventricle is 
dilated the duration of the sound is lessened. The loudness remains 
the same, or may be increased. Note, then, that a short systolic sound, 
loud, sharp, flapping, heard at the apex, indicates dilatation or feeble- 
ness. The tension of the ventricles and valves creating the sound is 
increased by internal pressure. The systolic sounds become like the 
diastolic, and may be distinguished from them with difficulty. With 
the finger on the apex or carotid artery, if the heart's action is slow 
the first sound will correspond Avith either pulsation. 

Alterations in the Rhythm. Foetal rhythm of the heart : 
Embryocardia — a term first used by Huchard to designate a condi- 
tion in which the pause between the heart sounds is of equal length. 
The first and second sounds are exactly alike, resembling the beat of the 
foetal heart. The sign is of importance in prognosis. In acute disease 
and in fever it indicates enfeeblement of the heart and reduction of 
arterial tension. In the later stages of Graves' disease it is a forerun- 
ner of death. It is distinguished from the rapid beat of the heart in 
tachycardia by the fact that in the latter condition the normal rhythm is 
preserved. 



360 



SPECIAL DIAGNOSIS. 



Cantering Rhythm of the Heart. The ear recognizes three sounds. 
The usual sounds may or may not be attended by murmur, and the 
interpolated sound may be dull or short and sudden. It may occur 
at various periods in the cardiac cycle, either before the systolic sound, 
after the diastolic sound, or during the diastolic pause. The rhythm 
recalls the sound of a horse cantering. It was termed by Bouillaud 
the bruit de galop. When the interpolated sound resembles the first or 
the second it is similar to reduplication of the sounds. It has been 
observed in hypertrophy of the heart, especially of the left ventricle ; 
dilatation of the heart; in adherent pericardium, with dilated hyper- 
trophy; in myocarditis, in the course of fevers; and in anaemia of high 
degree. It is heard loudest over the right and left ventricles. Potain 
thinks it is due to tension communicated to the wall of the ventricle by 
the entrance of blood into its cavity, and is more marked when the 
Avail is least distensible, as is possible when the tone of a muscle is ex- 
hausted. This triple rhythm is of bad prognostic omen in chronic 
Bright's disease. 

Reduplication of the Sounds. Reduplication, or apparent doubling, 
of the heart sounds occurs in various forms. In health the systolic 
souuds are created at the same time, or synchronously ; the diastolic 
sounds also correspond in time. In so-called reduplication one systolic 
sound may follow the other, or the aortic and pulmonary diastolic 
sounds may be created at distinct intervals. As has been stated, in 
galloping rhythm the idea of reduplication is sometimes transmitted to 
the ear. Reduplication may take place in health under the influence of 
respiratory movements. The systolic sounds may be doubled at the 
end of expiration and the commencement of inspiration, while the dia- 
stolic sounds are doubled at the end of inspiration and the commence- 
ment of expiration. In mitral disease reduplication, or want of syn- 
chronous closure of the two valves, is of frequent occurrence. The 
second sounds are doubled and heard over the base of the heart. 
Reduplication of the systolic sounds occurs in chronic Bright's disease. 

Reduplication, or Doubling of the Systolic Sounds, is heard over the 
apex or the right ventricle. Several explanations have been given for 
the cause of the reduplication. At first it was thought to be due to 
want of synchronism in the action of the veutricles — that one ventricle 
contracted before the other, due to the fact, of course, that the presence 
of blood stimulates one but not the other. By Hayden it was thought 
that reduplication of the first sound was due to the two major elemeuts 
of the sound acting asynchronously, the muscular sound taking place 
before the sound produced by the tension of the valves. Dr. George 
Johnson took the view that the reduplication was due to the contraction 
of the auricle and ventricle ; that the sound produced by the former 
was heard on account of hypertrophy of the auricle, and heard first 
because of the natural order of precedence. Thus far the reasons for 
each view have not been fully established. 

Sansom believes that reduplication of the first sound is due to the 
shock communicated to the contents of the ventricle just before systole, 
that is, during the auricular-systolic period ; in other words, it is due 
to the indirect effect of the auricular systole. The contraction of the 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



361 



auricle makes tense the auriculo-ventricular valve of the left side. If 
it occurs late in the diastole, or just before the systole, reduplication of 
the first sound is caused ; if early in the diastole, reduplication of the 
second sound is created. 

Reduplication of the Diastolic, or Second Sounds. While held by 
some authorities to occur in a large proportion of healthy individuals 
at the end of inspiration and the commencement of expiration, other 
observers, equally careful, think that it is extremely rare. It is of 
frequent occurrence in the patients of the Philadelphia Hospital. 
This is no doubt due to the fact that so many of the inmates are the 
subjects of all forms of lung disease, or disease of the vascular system, 
with muscular degeneration of the heart, that the equability of the pul- 
monic circulation is disturbed. There is no doubt that it can be 
modified or induced by respiration. It is usually heard at the end 
of inspiration and commencement of expiration. Actual reduplication 
of the second sound occurs when the normal asynchrouism of the 
closure of the aortic and pulmonary valves is exaggerated. It has been 
found that the valves of the pulmonary artery close a fraction of a 
second after the aortic valves. The ear usually fails to appreciate the 
difference unless there are differences of blood-pressure ; when doubled, 
and appreciated, therefore, it is indicative of a difference in blood- 
pressure between the two sides of the circulation. Increased resistance 
in either will lead to increased tension and quickened closure of the 
valve. The conditions that are associated with the doubling of the 
second sound are (1) and most frequently, mitral stenosis ; (2) obstruc- 
tion of the circulation in the lungs — tuberculosis, emphysema, and 
broncho-pneumonia; (3) dilatation of the right ventricle; (4) myo- 
carditis. The sound is heard at the second and third costal cartilages 
along the left edge of the sternum. It is frequently heard at the fourth 
and fifth cartilages at the left side. In cases of mitral stenosis it is 
heard nearest the apex. 

Simulated doubling is a sound produced at the mitral orifice. It 
is difficult to tell it from true doubling or reduplication. It 
is most distinct at the base of the heart along the left edge of 
the sternum. Occasionally it is more distinct near the apex than 
elsewhere. It occurs with the conditions found in true doubling. 
Cause. Sanson), Cheadle and others distinctly point out that the 
double second sound is of frequent occurrence, and that it is heard most 
frequently at the apex. Sansom thinks that the cause for simulated 
doubling of the second sound is the same as for doubling of the first. 
There is, first, the normal second sound ; second, a tension of the mitral 
curtain producing the second simulated sound. This tension is due to 
the shock of the blood coming from the auricle to the ventricle. 

Abnormal Sounds. The student has observed the character of the 
sounds and their rhythm. Abnormal sounds may be heard in addition 
to the normal sounds, or replacing them. These sounds are generated 
in the pericardium or in the heart itself. 

Abnormal Sounds in the Pericardium. They are known as 
friction sounds. They occur in the first stage of pericarditis, and are 
due to the rubbing of the inflamed surfaces together, either the con- 



362 



SPECIAL DIAGNOSIS. 



gested, vascular pericardium, or the membrane covered by lymph. The 
pericardial friction is usually of a to-and-fro character, and can be recog- 
nized as distinct from the heart sounds. It does not necessarily occur 
with each sound. It is a to-and-fro, systolic and diastolic sound. It 
may, however, be only systolic. It is heard over the body of the heart, 
usually in the third and fourth interspaces, or over the right ventricle. 
It is not transmitted away from the heart. It may be modified by 
pressure or influenced by the position of the patient. It may disappear 
entirely with change in position. The idea of nearness to the ear is 
given by the sound observed in the first stage of pericarditis. It may 
disappear during the period of effusion, to return after that is absorbed. 
It must be distinguished from the pleural friction. If the patient is 
asked to hold the breath, the latter will disappear. The pericardial 
friction is of cardiac rhythm, the pleural friction of respiratory rhythm. 
It must also be distinguished from the so-called exocardial friction 
sounds. The pleura adjacent to the pericardium may be inflamed. 
With each beat of the heart the rough surfaces of the pleura are agitated 
and generate a friction. It is seated along the edges of the right auricle 
or left ventricle. It is systolic in rhythm, but has the special characteristic 
that it is modified by respiration. It may be arrested if the patient holds 
his breath. It is increased by inspiration or diminished in expiration 
when the lung recedes from the heart in expiration. The pericardial 
friction must be distinguished from the crepitations and rales of cardiac 
rhythm produced by the impact of the heart against the lung. The 
distinctions between the pericardial friction and murmurs of the heart 
will be considered later. 

Abnormal Sounds within the Heart. They are known as 
murmurs, and may be due (1) to disease of the valve leaflets ; (2) to 
imperfect coaptation of the valves ; (3) to change in the character of 
the blood. 

Murmurs due to Valvular Disease. Any valve may be the seat 
of disease, causing interference with the flow of blood through the 
orifices. Either there is obstruction to the onward flow of blood 
through the orifice, or a return, or regurgitation, of blood backward 
because the valves cannot close properly. In either instance vibrations 
are produced, which, transmitted to the ear, constitute a murmur. On 
the one hand, a portion of a valve may be thrown into vibration by the 
current or by the obstructions of a cusp. The blood is thrown into 
eddies or vibrations. On the other hand vibration of the particles of 
blood is created when it is forced through a narrow orifice into a channel 
beyond of larger calibre. The act results in the production of what is 
known in physics as a fluid vein. The generation of the vein produces 
sound. As transmitted to the ear, the sound gives one the idea of 
rhythmical vibrations, and it is therefore in a measure a musical sound. 
Distinction from normal sounds : The character of the sound makes it 
possible to distinguish the murmurs from the normal sounds. The 
normal sounds are sounds of tension ; they are noises, not rhythmical 
vibration. Murmurs are soft and blowing, so-called bellows souuds, 
or musical. They may, on the other hand, be harsh and rough, 
varying in degree, compared to the sounds of sawing or filing. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



363 



Diagnosis of Different Murmurs. The student has learned that an 
abnormal sound or a murmur is present. He proceeds further, with 
two objects in view : first, to determine the orifice at which it is created 
by the position or seat of the murmur ; and second, to ascertain the 
nature of the lesion at the orifice, on account of which it is produced. 

The Seat of the Murmur. We are enabled accurately to determine 
the seat of the murmur, first, by noting its position of maximum inten- 
sity ; and second, the direction in which the murmur is transmitted. 

The Position of Maximum Intensity. The particular orifice at which 
a murmur is created has a point of maximum intensity at which 
the murmur is heard loudest, corresponding with the area at which 
the normal sound of the respective valve is heard loudest. It may 
be remembered that the orifices are closely situated, and that, there- 
fore, the murmurs must be generated within a small area, so small that 
it would be impossible to ascertain at which valve the murmur is 
created. By the laws of conduction of sound — hence by the influence of 
the solid heart upon the sounds — the murmurs are conducted away 
from the point of creation to stations at each of which the respective 
valve sound is heard with greatest intensity. 

1. Murmurs at the Apex — the Mitral Area. The murmur is heard 
loudest, or with the greatest intensity, at the apex. It is due to disease 
of the mitral valve, because the left ventricle is nearest the chest wall 
at this point. The solid muscle of the ventricle conducts the sound 
generated at its valve. 

2. Murmurs at the Xiphoid Cartilage — the Tricuspid Area. The 
murmur is heard loudest at the xiphoid cartilage. It is due to regurgi- 
tation at the tricuspid orifice, and is heard most distinctly over the 
lower portion of the sternum, and along the left edge, because the right 
ventricle is in apposition with the chest wall at this point. 

3. Murmurs at the Second Costal Cartilage or Second Interspace on the 
Right — the Aortic Area. When the murmur is heard with greatest 
intensity at this point it is due to disease of the aortic valves, because 
the murmur generated at the aortic orifice is conducted to this region by 
the aorta, which comes nearest to the surface of the chest at this point. 

4. Murmurs in the Second Left Interspace — the Pulmonic Area. A 
murmur heard loudest at the second interspace along the left edge of the 
sternum is generated at the pulmonary valve ; it is heard loudest in 
this area because the pulmonary artery is nearest the chest at this point. 

The Direction of Transmission. This will be considered later, al- 
though it may be said murmurs due to disease of the aortic valve are 
transmitted upward from the base ; murmurs due to disease of the mitral 
valve are transmitted away from the apex and toward the axilla. 

Having determined the point of maximum intensity of the murmur, 
hence the valve which is the seat of disease, we next wish to determine 
the nature of the lesion on account of which the murmur is created. 
The physical conditions which produce murmurs are present both dur- 
ing the time when the valves should be closed and also at the time 
when the valves are open and the blood is flowing through the orifices. 
A murmur which is produced when the valves should be closed, permit- 
ting blood to flow through an orifice, is known as the murmur of 



364 



SPECIAL DIAGNOSIS. 



regurgitation. A murmur that occurs at the time the blood should in 
health be passiug through an orifice is known as a murmur of obstruc- 
tion. We have to determine whether the murmur at an orifice is due 
to regurgitation or whether it is due to obstruction. This is ascertained 
by the time of the murmur and by the direction in which it is traus- 
mitted. 

The Time of the Murmur. Murmurs in the Mitral Area. The 
murmur is heard loudest at the apex. It occurs with the systole. 

1. In health, during this time, the auriculo-ventricular valve is 
closed. If a murmur replaces the systolic souud there is such disease 
as to permit of a backward flow of blood, or regurgitation, into the 
auricle. It is the murmur of mitral regurgitation. It is a systolic 
murmur. 

2. It occurs before the systole, or during the latter part of the dias- 
tole. During this time, in health, the blood is flowing through the left 
auricle to the left veutricle. There must be such disease as to cause 
obstruction to the flow of blood. It is the murmur of mitral obstruc- 
tion. It is a presystolic murmur. 

Murmurs in the Tricuspid Area. The murmur is heard at the xiphoid 
cartilage. 1. It is systolic in time. For the same reason as on the 
left side, the murmur is due to disease which permits of regurgitation, 
tricuspid regurgitation. 

2. In rare instances a murmur may be heard in the tricuspid area 
in the diastole, due to tricuspid obstruction. It is so rare, however, that 
it does not need further consideration. 

Murmurs in the Aortic Area. The murmur is heard loudest at the 
second costal cartilage on the right. 1. It is heard with the systole. 
During this time the blood is flowing from the ventricle into the aorta. 
There is such disease as to cause obstruction at the orifice. It is the 
murmur of aortic obstruction. It is a systolic murmur. 

2. It occurs with the second sound. During this time, in health, the 
blood falls back on the aortic leaflets. If they are diseased in such a 
degree as to permit a portion of the blood to flow backward into the 
ventricle, a murmur is created. Regurgitation is produced and a mur- 
mur is heard — the murmur of aortic regurgitation. It is a diastolic 
murmur. 

Murmurs in the Pulmonary Area. 1. It occurs with the systole. 
The murmur is heard loudest at the second interspace on the left. The 
pulmonary orifice is affected in a similar manner as the aortic orifice 
under the same circumstances. The murmur is due to pulmonary 
obstruction. It is exceedingly rare. 

2. It occurs with the diastole, for the same cause as in aortic regurgi- 
tation. It is of such extreme rarity it can practically be excluded. It 
is due to pulmonary regurgitation. 

Murmurs are divided as to time into systolic and diastolic murmurs. 
The above shows that we may have practically only three systolic and 
two diastolic murmurs. The systolic murmurs are aortic obstruction 
and mitral and tricuspid regurgitation. The diastolic murmurs are 
aortic regurgitation and mitral obstruction ; the former occurs in the 
first part of the diastole and represses the second sound j the latter 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



365 



in the diastole, either in the last part or before the systole, or in the 
midst of the diastole. 

Direction in which the Murmur is Transmitted. This 
depends upon the situation of the murmur and the time at which it is 
produced. 

Murmurs in the Mitral Area. A murmur which is produced at the 
apex with the systole, caused by regurgitation at the mitral orifice, is 
transmitted into the axilla and may be heard at the angle of the 
scapula. The murmur which is produced in the same area before the 
systole is not transmitted over the body of the heart. It is heard at 
the apex, or a little inside of the apex, or may rarely have its point of 
maximum intensity in the third interspace. 

Murmurs in the Tricuspid Area. The murmur of tricuspid regurgi- 
tation is not transmitted. It is heard over a relatively large area, 
depending upon the degree of loudness of the sounds. 

Murmurs in the Aortic Area. The murmur, systolic in time, heard 
at the second costal cartilage on the right, due to aortic obstruction, i& 
transmitted in the direction of the blood current. The sound is con- 
ducted by the vessels and by the fluid ; it is therefore heard along the 
course of the aorta and in the carotid arteries. The murmur of aortic 
regurgitation, heard in the same area, is transmitted downward along 
the course of the sternum. It may be transmitted to the apex, or may 
be along the sternum alone. The left ventricle conducts this murmur. 

Character of Murmurs. Murmurs are studied in accordance 
with the above, as to their situation, their time, and the direction in 
which they are transmitted. In addition, we study the character of 
the murmur and the degree of loudness. By the character of the murmur 
we are aided (1) in distinguishing them from heart sounds; (2) in 
estimating the nature of the lesion that produces the murmur; (3) in 
judging, in the case of murmur of mitral obstruction, of the presence 
or absence of that disease. 

From Normal Sounds. Normal sounds are sounds of tension ; mur- 
murs are sounds of vibration. The normal sounds of the heart have 
been recognized by syllables "ubb" " dupp," " od," and abnormal 
sounds of endocardial origin by "uf" "uv" "us" "ush" or by full 
vow r el sounds as "oo" "u" " ah" and "aw" by musical tones, or 
by interrupted tones, or hearing general sounds as "urr" or "orr." 
The nature of the lesion. The murmurs may be rough or rasping, 
musical or whistling in character. They may be high in pitch or low 
in pitch. Murmurs that are rough and high in pitch, are usually due 
to disease of the valves which is caused by thickening or stiffening of the 
leaflets, or to the projection of an atheromatous plate into the lumen of 
the orifice. Such conditions occur in chronic endarteritis and chronic 
endocarditis or valvulitis. On the other hand, murmurs that are soft 
and low in pitch are usually due to a physical condition which causes 
swelling of the valve or occlusion by soft exudations ; they are heard 
in endocarditis of rheumatic origin, or the malignant form of endocar- 
ditis. The only murmur which has special characteristics is the murmur 
of mitral obstruction. It is a prolonged murmur of a churning or 
grinding character, sometimes rippling, and from which we get the idea 



366 



SPECIAL DIAGNOSIS. 



that fluid is being forced through a narrow channel. It is usually 
presystolic, but may occur in the middle of the diastole. Loudness. 
The loudness of the murmur is not of special, significance, although, in 
general, it maybe said that it indicates good compensation, and that the 
force which generates the murmur is sufficient to meet the demands of 
the circulation. Loud murmurs may become weak, and this change in 
character of the sound is of serious omen. 

Change of Murmur. The student will often find that after a patient 
has been under treatment for a short time the murmurs disappear. This 
is probably due to the fact that there is complete compensation. On 
the other hand, it may be necessary to bring out a faint murmur or 
increase its intensity by having the patient move about ; this renders 
it more distinct by inducing more rapid action of the heart. 

Murmurs due to Incompetency. The valves are sometimes 
unable to close properly. The cavity of the ventricles may increase 
in size, so that the valves do not coaptate properly to close the widened 
orifice. The tricuspid and mitral valve leaflets are often thus made 
incompetent. Mitral and tricuspid regurgitation ensue. The murmurs 
are soft and low in pitch and not widely transmitted ; the heart is 
dilated. 

The Murmurs of Anaemia. Having ascertained a murmur and 
the orifice at which it is created, we have to distinguish whether the 
murmur is due to disease of the valves or whether it is due to anaemia. 
The murmurs of anaemia have some characteristics which aid in distin- 
guishing them from the true organic murmurs. The most important of 
these are: (1) the situation of the murmur; (2) its character; (3) the 
direction in which it is transmitted; (4) the time; (5) the associate con- 
ditions. The murmurs of anaemia may be heard at any orifice, but are 
usually heard at the second costal cartilage, or the third interspace, on 
the left side. They are generated at the pulmonary orifice, or in the 
cone of the right ventricle. They are soft in character, and low in pitch. 
They are systolic in time and are not transmitted away from the heart. 
The murmur at the pulmonary orifice may be heard as high as the 
second interspace, but otherwise is not transmitted. Murmurs of anaemia 
are also heard at the apex, at the aortic cartilage, and over the tricuspid 
area. They are comparatively infrequent in these situations, but par- 
take of the same nature as the murmur heard at the pulmonary orifice. 
The heart does not undergo hypertrophy of special portions. Dilata- 
tion, fatty degeneration or hypertrophy may be present. We distinguish 
the murmur of anaemia, in addition, by its association with murmurs in 
other parts of the vascular system. The murmur in the jugular veins 
is usually associated with an anaemic murmur heard over the heart. Its 
characteristics aud mode of distinction have been described elsewhere. 

The Significance of Murmurs. Murmurs that are heard at the 
various orifices indicate disease at the orifices causing obstruction or incom- 
petency of the valve, or disease of the blood, or disease of the vessels in 
intimate relation with the heart. The systolic murmur at the second costal 
cartilage on the right may be heard in structural disease at the aortic ori- 
fice, causing obstruction or atheroma of the aorta, or in cases of aneurism 
just above the valves, or of anaemia, or chlorosis, and in some affections 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



367 



with vasomotor neuroses, as Graves' disease. Before concluding that 
the murmur is due to disease of the valves we must decide the absence 
of the other three conditions. Atheroma of the aorta is most difficult to 
distinguish, because the character of the murmur is the same and the 
associated conditions are similar. In both there may be a previous 
history of gout, rheumatism, syphilis, or of alcoholism. The latter is 
associated with atheroma in other arteries of the body, and with degen- 
erative changes that accompany atheroma. Iu young subjects, in whom 
there has been a direct history of rheumatism, or when the process has 
followed septicaemia, the probabilities are, in nearly all the cases, that the 
murmur is due to aortic obstruction. To distinguish the murmur of 
anaemia, chlorosis, or Graves' disease is often difficult. The associate 
symptoms are different, and then the changes in the blood are such as to 
indicate the nature of the murmur. 

Secondary Effect of Valve Lesions on the Heart and 
Pulse. While we are enabled by the time of the murmur, the position, 
and the direction of transmission, to affirm the nature of the disease at 
respective valve orifices, other physical signs of diagnostic significance 
aid us in determining more precisely the lesion and its seat. They de- 
pend upon the secondary effects of the lesion upon the heart and upon 
the circulation. In aortic obstruction, on account of obstruction to the 
flow of blood, the left ventricle hypertrophies; moreover, the blood 
stream is lessened in volume, and hence the pulse is small and of high 
tension. The physical signs of hypertrophy and small pulse are cor- 
roborative evidence of this lesion at the left orifice. In aortic regurgi- 
tation the blood flows back into the ventricles. On this account, 
therefore, some dilatation takes place, a dilatation which, if compensa- 
tion is perfect, is overcome by hypertrophy. The signs, however, of 
enlarged left heart are present, as indicated by inspection, palpation, 
and percussion. But the pulse of aortic regurgitation is of the greatest 
diagnostic significance. With the finger on the radial, the impression 
is at once received of recedence of the pulse wave as soon as it strikes 
the finger. This is more marked if the hand is elevated. It is the 
water-hammer, or Corrigan's, pulse. In mitral regurgitation, the left 
auricle does not change, but the stress is thrown upon the right side 
of the heart, and we have the signs of right-sided hypertrophy and 
dilatation ; but more marked than this is the evidence of tension of the 
pulmonary artery, which is shown by accentuation of the second sound 
(see p. 358). In mitral regurgitation, the blood flows back into the 
auricle and engorges the venous system. The arterial system is devoid 
of blood, and hence the artery is emptied. The pulse is small and 
feeble; the coronary arteries are not fully supplied with blood, in con- 
sequence of which there is a diminished amount of blood to nourish the 
ventricles. Dilatation or failure in nutrition soon ensues, and the heart 
is unable to do the work expected of it. In addition to the small and 
feeble pulse, there are inefficient and hurried contractions, on account of 
which the pulse is irregular and intermittent. 

In mitral obstruction, in addition to the characteristic murmur, the 
thrill is of great significance. Moreover, the left auricle hypertrophies, 
and shortly afterward the right heart, It is accompanied by an accentu- 



368 



SPECIAL DIAGNOSIS. 



ated pulmonary second sound, and frequently by doubling of that 
sound. The pulse is small and feeble. 

Examination of the Arteries and Veins. The state of the cir- 
culation in the arteries and veins is greatly influenced by the condition 
of the heart. Examination of them yields data of diagnostic value in the 
discrimination of heart disease. It is appropriate that such examination 
should be considered before proceeding with the diseases of the heart. 

The Arteries. Inspection. By inspection pulsation may be ob- 
served or any undue swelling or change in the course of the vessels. 
With the exception of pulsation in the carotids, which may temporarily 
increase under excitement, pulsation of the vessels is not usually seen in 
health. The arteries open for inspection are, in old people, the aorta 
rarely at the episternal notch, the temporal, the innominate, the carotids, 
the subclavian, the brachial and radial arteries, the abdominal aorta in 
thin subjects, the femoral arteries and the posterior tibials. 

The Arteries in the Neck. Temporary pulsation of these 
arteries has been spoken of. This occurs in excitement. It is com- 
monly seen in anaemia. The throbbing is marked in exophthalmic 
goitre. It is striking in aortic regurgitation. It often attends the vas- 
cular changes of old age. It may be due to atheroma or aneurism. It 
is always suggestive of aortic valvular disease. The innominate artery 
often visibly pulsates in the neck, and has been observed to be so large 
as to simulate aneurism. The youthful age of the patient points to 
throbbing of neurosal or hsemic origin. The subclavians may pulsate 
for the reasons above mentioned. They may also be seen to pulsate if 
the lungs are consolidated or shrunken by disease. 

The Aorta. Pulsation of the thoracic aorta is determined by the 
occurrence of an impulse in the course of the vessel. The position 
of this impulse will be described under the head of aneurism. Pulsa- 
tions in the course of the aorta are not always due to disease of the 
vessels. The aorta may be pushed against the chest wall, or the lung 
structure which overlaps it normally may be withdrawn by shrinkage. 

The Abdominal Aorta. Pulsation of the abdominal aorta is often 
the cause of serious distress aud complaint. The violent throbbing 
keeps the patient awake at night, and renders his previously nervous 
state more nervous and irritable. The pulsation is usually seen in the 
epigastrium. It is more frequent when the vessel is not diseased, in 
neurasthenic subjects. It occurs reflexly in patients with dyspepsia or 
organic disease in the upper abdominal tract. The shock of the pulsa- 
tion is transmitted to the hand with considerable violence. The impulse 
is diffused, but not expansile. 

Epigastric pulsation is also due to the transmission of the impulse of 
the aorta by enlargement of the pancreas or tumors of the stomach or 
the omentum. The transmitted pulsation is distinct. It is believed to 
be present when the tumor can be defined and when a sensation of lift- 
ing is transmitted to the hand. The physical signs of aneurism are 
absent. If the patient lies on the abdomen, or in the knee-chest posi- 
tion, the tumor falls away from the aorta, and the impulse is not readily 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



369 



transmitted. Epigastric pulsation is also due to aneurism of the ab- 
dominal aorta. The pulsation is distensile or expansile, and the aneur- 
ysmal sac can be defined at times. The other physical signs of aneurism 
are present usually, namely, thrill, dulness over the tumor, a murmur 
on auscultation. Often in the above conditions reliauce cannot be 
placed on the physical signs alone. The history of the subjective 
symptoms of disease of other structures must be carefully inquired into. 
Aneurism rarely occurs without some evidence of arterial sclerosis or 
some physical effect upon the circulation in the bloodvessels. Accentua- 
tion of aortic second sound on the one hand, variations in the femoral 
pulse, high arterial tension and the evidences of sclerosis, favor aneur- 
ism. While epigastric pulsation due to pulsation of the aorta usually 
occurs in neurotic subjects, and hence in the earlier periods of life, yet 
such pulsation is frequently seen in the aged, and, with fibrous thickening 
about the pylorus, or contraction of the omentum, it may easily be con- 
founded with malignant disease, which is also more common during this 
period of life. Cancer of the stomach has been diagnosticated under 
these circumstances when the pulsation was simply reflex from chronic 
gastritis. Some time ago a private patient in the Presbyterian Hospital 
had extreme pulsation of the abdominal aorta with great local discom- 
fort on account of the throbbing. She was sixty-five years of age, 
and had within the past two years nursed her son through tuberculosis. 
She failed in health, and came to the hospital emaciated, with pro- 
nounced chronic gastritis and diarrhoea. On examination, above the 
umbilicus a distinct tumor was felt, which she had been told was due 
to carcinoma. It was hard and painless ; the physical signs of aneur- 
ism were not present ; the pulsation was extreme. A second tumor, 
not so large, was felt in the right hypochondriac region. Both tumors 
were dull upon percussion and surrounded by tympanitic areas. They 
were also movable. While it is impossible to state the nature of the 
tumors, it seemed to me they were tuberculous, or simply fibrous, and 
would not influence the patient's immediate welfare. Under treatment, 
the pulsation disappeared ; the gastro-intestinal symptoms were relieved 
entirely ; the patient rapidly gained in weight and strength ; the tumors 
continued, but they are not so distinctly outlined because the previously 
scaphoid abdomen has become distended (six months under observa- 
tion). The questions arose for decision : Was the epigastric pulsation 
due to a throbbing aorta or transmitted by an obscurely defined mass 
in that region ? Were the other tumors secondary carcinomatous nodules ? 
The diagnosis must be made by attention to all concomitant circum- 
stances and phenomena that surround cancer. (See Symptomatology 
of Morbid Processes.) Fcecal accumulations in the colon may be made 
to pulsate by the impulse of the aorta and cause exaggerated epigastric 
impulse. Evacuation of the bowels must be secured before definite 
conclusions are arrived at. 

Epigastric impulses due to the above-mentioned causes must not be 
confounded with the impulse in the same situation due to hypertrophy 
of the right ventricle or to the shock of the hypertrophied heart trans- 
mitted to the left lobe of the liver. In hypertrophy of the right ven- 
tricle or dislocation of the heart from disease within the chest, the 

24 



370 



SPECIAL DIAGNOSIS. 



impulse may be seen to the right or left of the xiphoid cartilage. The 
symptoms and signs of right-ventricle hypertrophy explain the pulsa- 
tion. 

The Smaller Arteries. By inspection of the arteries beyond the 
abdominal aorta we are able more distinctly to recognize frequently the 
condition known as arterio-sclerosis. Similar examination of the 
brachial and radial arteries reveals the same condition the changes of 
which are spoken of when that disease is considered. (See Arterio- 
sclerosis.) But pulsation of the above-mentioned peripheral arteries 
may be due to other causes. In hypertrophy of the left ventricle 
arterial pulsation is prominent, although more marked in the vessels 
near the heart, as the carotids. In insufficiency or regurgitation at the 
aortic orifice pulsation is also frequently seen. 

Elongation of this artery, so that instead of a straight tube, it be- 
comes a sinuous canal, turning and twisting at short intervals, is seen 
in endarteritis. 

Capillary Pulse. The capillary pulse is seen under the finger- 
nails or in the skin after hyperemia is induced by the observer firmly 
stroking the skin with his nail. It may be seen inside the lips, if they 
are pressed upon by a piece of glass. There is rhythmical pulsation of 
the capillaries, from which the surface becomes alternately white and 
red. It is a sign of aortic insufficiency. 

Palpation. Reference must be made to the sections on aneurism, 
arterio-sclerosis, and the pulse. The results of inspection are confirmed. 
In addition, the artery is examined to determine its tension, the charac- 
ter of the coats, and the presence of thrills. Pulsation of Organs. It 
is said that in aortic regurgitation an arterial liver pulse, similar to the 
venous liver pulse can be felt when the hands are placed over that organ. 
Similar pulsation may be felt in the spleen. 

In examining the arteries it is important, as has been detailed in the 
pulse, to compare the arteries of the two sides. Often the pulse wave 
in them is found to be unequal in force, in volume, and in time. This 
is almost always due to obstruction to the passage of the blood. T\ nen 
not due to endarteritis or to aneurism, it is due to pressure of a tumor 
on the vessel somewhere in its course. A thrombus or embolus in the 
artery may likewise cause the condition. A difference in the radial 
and the femoral pulse points to obstruction in the thoracic or abdominal 
aorta. Anatomical variations must be remembered. 

The Pulse. 

The pulse is an index of the force and rhythm of the heart's action 
and of the state of pressure, or tension, which it maintains in the 
arteries. 

General Considerations. The frequency of the pulse before 
birth is from 120 to 140 beats in the minute. From this time it dimin- 
ishes in frequency up to adult life, 72 being then accepted as an 
average ; the number of beats, however, is often under 72, and some- 
times over that. In old age the pulse rate is again increased. Sex has 



HEART 3 BLOODVESSELS, AND MEDIASTINUM. 



371 



some influence. The rate is slightly higher in females than in males 
of the same age. 

The frequency of the pulse is subject to diurnal variations, at times 
corresponding with the diurnal rise and fall of temperature. The rate 
will therefore be highest in the afternoon and evening and lowest in 
the early morning hours. 

The position of the body has also a modifying influence. The pulse 
is more frequent when a person is standing than when he is sitting, 
and more frequent when he is sitting than when he is lying down. 
Walking, running, bodily and mental exertion, fear, and excitement all 
tend to accelerate the pulse. 

During and for one or two hours after a meal the pulse rate is 
higher, especially if an alcoholic or other stimulant, such as coffee, has 
been taken. 

How to Take the Pulse. To make a correct count of the fre- 
quency of the pulse, the conditions just mentioned, as normally modifying 
its rate, should be borne in mind. If the object of the count is to 
determine the rate which is normal for a particular individual, several 
counts will be necessary at different times and under different condi- 
tions, such as sitting and standing. The best time for the physician to 
take the pulse will have to be determined by his own judgment in each 
case. If the patient comes to his office and is excited by the prospect 
of an examination, it will be well to wait until he becomes calm. On 
the other hand, if he is calm at first, a count at that time is to be pre- 
ferred to one made after the patient has been disturbed by a physical 
examination. In the same manner, on visiting a patient at his house, 
the judgment of the physician must decide whether to count the pulse 
immediately on his arrival or to postpone it until, by general conversa- 
tion, all apprehension and alarm on the part of the patient have been 
allayed. In general it may be said that if the physician finds, upon 
his arrival, that the pulse is more frequent than the condition of the 
patient would lead him to expect, he should wait a while, endeavor to 
find out whether anything has served temporarily to disturb the circu- 
lation, and then make the count w T hen the conditions are most favorable. 
Some patients are so nervous that the mere act of placing the finger 
upon the wrist sends the pulse rate up ten or twenty beats in the 
minute. In such cases the effort should be made to obtain a count 
without the patient's knowledge by observing the pulsations of the 
temporal or carotid. In other cases it may be well to entrust the count- 
ing of the pulse to the nurse or a member of the family. In infants 
and young children, count while they are asleep. In febrile conditions 
the count is more likely to be too high than too low. 

In hospital practice, or when a nurse is in constant attendance, the 
pulse and respiration should be taken at the same times as the tem- 
perature. But the nurse must be warned against taking them under 
dissimilar conditions upon successive days. For example, the pulse 
should not be taken one day while the patient is lying down, quiet 
and comfortable, and compared with the count the next day when the 
patient is sitting up or has just had some hot liquids, or a spell of 
coughing, or been subjected to some other disturbing influence. 



372 



SPECIAL DIAGNOSIS. 



The preferable position is the recumbent one in the case of patients 
in bed, and the sitting position in those not confined to bed. Care 
should be exercised in all cases to see that the patient's position is easy 
and comfortable and that nothing obstructs the artery or interferes with 
the unimpaired flow of the blood. 

The wrist is the place usually selected at which to feel the pulse At 
this point the radial artery passes over the radius, and can be readily 
compressed and its character made out. An old-fashioned rule pre- 
scribes that three fingers should be applied to the artery, the index 
finger of the physician being nearest the heart. In particular cases it 
may be advisable to count the pulse at the temporal or carotid artery. 
The fingers should be applied so that the beats can be most distinctly 
felt. The beats are counted for fifteen seconds by the second hand of a 
watch when only an approximately correct count is desired, or when 
time is a factor, and then multiplied by four. It is better to count the 
pulse for half a minute, and still better for a full minute. 

The arteries of the two sides must be compared. Difference in the 
force, volume, and time may be due to the anomalous distribution of 
arteries. In disease, it may occur in aneurism and atheroma, in pres- 
sure on the trunk from external disease, and in embolism and thrombosis. 

Condition of the Walls of the Artery. The condition of 
the artery is often of more importance thau the pulse rate. A healthy 
radial artery in a person not advanced in years can be compressed 
easily against the radius without the finger being able to differentiate 
the artery from the other tissues. But as age advances, and as the 
result of certain constitutional diseases — syphilis, gout, chronic endar- 
teritis, alcoholism, and others — the artery tends to become thicker, so 
that in pronounced cases it cannot be obliterated, but is rolled like a 
cord or pipe-stem between the compressing fingers and the bone. The 
small specks or plates of atheroma, feeling like hard particles in the 
coats of the artery, may be felt. The artery has a beaded feeling. Fatty 
degeneration of the organs is likely to occur when the arteries are in 
this condition, and apoplexy is to be feared. 

Tension. Tension is the word used to express the degree of blood 
pressure — that is, of distention of the arteries. Normally, the pulse 
nearly or quite subsides between the beats, but little pressure being re- 
quired to obliterate it. High tension may be said to exist when the 
artery remains continuously full between the beats (Broadbent). It is 
produced by plethora ; increased heart action ; contraction of the arte- 
rioles, as by chill ; and obstruction in the capillaries. The conditions 
which bring about obstruction in the capillaries in the order in which 
they are enumerated by Broadbent are : (1.) Age. The liability to high 
arterial tension increases with the age, especially after middle-life. (2.) 
Heredity. There is in some families a marked tendency to high ten- 
sion. The younger members show its effects in headaches and bilious 
attacks, while the older ones develop chronic heart disease and apo- 
plexy. (3.) Disease of the kidney. Parenchymatous, but especially 
interstitial nephritis, is associated with high arterial tension ; this, with 
accentuation of the aortic second sound, is one of the early and, there- 
fore, one of the most valuable indications of chronic Bright's disease. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



373 



(4.) Gout. Gout and lithaernia are almost always accompanied by high 
arterial tension. (5.) Diabetes in old persons associated with gout. 
(6.) Lead-poisouing. (7.) Pregnancy. (8.) Anaemia. (9.) Emphysema 
and chronic bronchitis. (10.) Mitral steuosis. 

As regards arterial tension in persons presenting signs of angina 
pectoris, Sansom asserts that if the tension is increased, even though 
the signs are not typical, the fear, present or remote, of true angina is 
justified. On the other hand, if there is persistent low tension, espe- 
cially during the painful crisis, it is almost certain the affection is a 
false angina. 

Low tension of the pulse is characterized by a softness and a compressi- 
bility in excess of the normal. This, like the high-tension pulse, may 
be a family peculiarity. It is met with in conditions of great depres- 
sion and exhaustion and wherever there is marked cardiac weakness. It 
is most common in fevers, particularly in typhoid, in which also an 
accompaniment of low-tension pulse, namely, dicrotism, is met with 
in a marked degree. Fat persons are apt to have low-tension pulses, 
and it may occur in any person temporarily under the influence of ex- 
ternal warmth and moisture, such as a hot bath, or after taking hot 
drinks, or under the influence of depressing emotions, diarrhoea, or 
sudden copious urination. 

Volume. The volume of the pulse should be noted. It is usually 
large in conditions of pyrexia and when the tension is low. A small 
pulse is met with in many conditions other than weakness of the heart 
muscle In aortic stenosis the pulse is small, and in mitral stenosis it 
is small, of high tension, and frequently irregular. In general contrac- 
tion of the arterioles, as happens under the influence of a chill, the 
pulse is small. In Bright' s disease it is sometimes very small, slow, and 
hard. Some care will be required to differentiate such a pulse from a 
weak pulse. In acute peritonitis the pulse is apt to be small and hard. 

Rhythm. The rhythm of the pulse is of diagnostic importance. In 
health one beat succeeds another at equal intervals of time, and the suc- 
cessive beats are of the same force and quality. Here also, however, 
as in other conditions, there are variations within physiological limit. 
In some persons the pulse rate is somewhat accelerated during respira- 
tion and becomes slowed in the pauses which follow breathing. 

In disease, disturbance of the rhythm occurs as intermission or as 
irregularity. Intermission signifies a stopping of a pulse beat ; several 
normal pulse beats succeed each other, and then the pulse is absent dur- 
ing the time occupied by one or two beats. The intermission may occur 
at regular or at irregular intervals — that is to say, every third, fifth, or 
sixth beat may be wanting, or the intermission may be irregular — now 
a second, the next time a fifth, or a third beat being absent. Moreover, 
the intermittent pulse may be constant, or it may, and more frequently 
is, only occasional. It is not characteristic of any one disease or con- 
dition, and it may exist without the patient's knowledge and without 
producing any perceptible effect upon his health. Sometimes it is met 
with in a fatty heart, and this disease may be suspected if the inter- 
mittent pulse is associated with a weak first sound of the heart without 
valvular lesion, and evidences of failing circulation, such as oedema of 



374 



SPECIAL DIAGNOSIS. 



the feet. More frequently, however, the intermittency is a symptom of 
nervous depression, or is caused by tea, coffee, tobacco, or digitalis. So 
far as prognosis is concerned, it is much less serious than irregularity. 
Broadbent says he has met with it at the age of eighty, when it has 
been known to exist for forty years. 

Irregularity is characterized by differences in time, force, or volume 
of successive beats. A full beat is succeeded by another, which is 
smaller and weaker, or successive beats occur at irregular intervals of 
time. Irregularity may or may not be associated with intermission. 
In advanced cases of mitral stenosis the pulse is both irregular and 
intermittent. The irregularity may be habitual or occasional ; the 
former is due most frequently to mitral lesions, but sometimes occurs 
without assignable cause, and is attributed to disturbance of the nerve 
supply ; the latter is due to digestive disturbances and to the effect of 
nicotine and digitalis. Irregularity is not incompatible with health, but 
is much more likely to be of serious import than intermission. It occurs 
in diseases of the brain, in degeneration of the heart as well as in valvu- 
lar lesions, and in grave cases of febrile diseases, such as typhus and 
typhoid, when the heart muscle is involved. Some cases of Graves' 
disease are characterized by great irregularity instead of excessive 
rapidity of the pulse. Irregularity may occur in rheumatoid arthritis 
also, though increased frequency is the rule. 

The Pulse in Diagnosis. The frequency of the pulse is of aid in 
diagnosis. 1. The pulse is increased in frequency in all febrile diseases, 
and generally in the proportion of eight to ten beats for each degree of 
rise in temperature above 98°. But there are important exceptions. 
In typhoid fever the pulse is slower in proportion to the temperature and 
the gravity of the disease than in most of the other acute febrile dis- 
eases. It may not beat above 85 in mild cases, and in severe cases 
frequently does not rise above 100. Consequently a pulse of 120 is of 
much graver import than it would be in other diseases. It may be 
more frequent during convalescence than during the febrile stage. This 
pulse rate helps to differentiate it from tuberculosis, malignant endo- 
carditis, and septicaemia. 

2. The pulse of scarlet fever often aids materially in diagnosis. A 
pulse of 120 to 160 is the rule from the development of the sore-throat 
to the completion of the eruption. In measles, rubella, diphtheria, and 
follicular tonsillitis it is much slower during the early stages. 

3. In Graves' disease great frequency of the pulse is the essential 
and the most constant symptom of the disease. The pulse may be con- 
stantly considerably over 100, and in attacks of palpitation 200 or 
more. In these attacks there may or may not be precordial distress and 
mental anxiety. Here belong the cases described as paroxysmal hurry 
of the heart, etc., the thyroid and ophthalmic symptoms being absent. 

4. Cases have been reported of extreme frequency of the pulse (160- 
240) without palpitation, dyspnoea, or any sign of Graves' disease. 
Some of the patients have been able to perform much bodily and mental 
labor, notwithstanding that the rate mentioned was maintained persist- 
ently for weeks. To this class of cases the name tachycardia has been 
applied until their pathology is understood. 



HEART, BLOODVESSELS, 



AND MEDIASTINUM. 



375 



. 5. Mitral stenosis maybe latent lid til great excitement, over-exertion, 
and particularly running or forced marches bring on palpitation, or 
simply abnormal and persistent frequency of the heart's action, with or 
without dyspnoea. In all forms of valvular disease, except aortic 
stenosis, with failing compensation, in collapse, in weakening of the 
heart, and in central or peripheral vagus disease, the pulse is increased. 

6. Attention has been called, especially by Dr. J. Kent Spender, to 
acceleration of the pulse as an early symptom of rheumatoid arthritis. 
The pulse increases gradually until it reaches a range of 110-120, and 
it persists at that rate with little diurnal variation, even after the 
arthritic symptoms subside. 

7. In locomotor ataxia permanent moderate acceleration of the pulse 
(90-100) is a frequent symptom. 

8. In puerperium increased frequency with irregularity of the pulse 
is a surer indication of intra-uterine mischief than is the temperature. 
So, too, in all cases in which there is a focus of suppuration so situated 
that the pus can be absorbed into the circulation but not discharged ex- 
ternally, the pulse shows by its increased frequency that absorption is 
going on. 

A slow pulse (bradycardia), under 60, like a frequent pulse, is some- 
times habitual, and sometimes a family characteristic. Pathologically, 
it is met with in conditions which increase the resistance in the arteries, 
such as Bright' s disease, especially acute glomerulo-nephritis ; but it is 
especially common in jaundice. The bile acids have the effect of slow- 
ing the heart. 

A slow pulse is met with in certain forms of heart disease, as aortic 
stenosis, but it is not constant in any of them. It occurs in fatty degen- 
eration, especially when due to obstruction, by atheroma or otherwise, 
of the coronary arteries. When it appears in the late stages of val- 
vular affections or specific diseases with cerebral symptoms it is usually 
a sign of danger. It is seen in articular rheumatism (Atkinson). 
According to Riegel it is most common in convalescence from acute dis- 
ease, particularly pneumonia, typhoid fever, erysipelas, and rheumatic 
fever. It is also frequently encountered in diseases of the digestive 
organs, and of the urinary organs, particularly acute nephritis. More- 
over, it is generally slow in myxedema, and slow and irregular in 
epilepsy. It is slow not uncommonly, also, in melancholia and in the 
early stage of cerebral meningitis and in tumors and cerebral hemor- 
rhage. 

The Sphygmograph. The sphygmograph, as its name implies, is 
an instrument for recording in writing the volume, force, frequency, 
tension, and general characteristics of the pulse. Many forms of the 
instrument have been devised since the first one of Marey. The later 
models have the advantage of simplicity and ease of application. One 
of the most convenient is Dudgeon's. It has its faults, particularly in 
exaggerating the vibrations when the pulse is large and the heart is 
acting violently ; nevertheless, with care, trustworthy tracings can be 
obtained in all ordinary cases. No matter what instrument is used, the 
value of the tracing depends very largely upon the personal skill and 
experience of the one who takes the tracing ; hence the sphygmograph 



376 



SPECIAL DIAGNOSIS. 



occupies a position very different from the thermometer and other 
instruments of precision. While it is true that a person can learn to 
detect nearly all the variations of the pulse by palpation alone, yet the 
tracing has the great advantage of permanency, and many persons are 
led to palpate the pulse more carefully by seeing in a sphygmographic 
tracing a dicrotism or irregularity which had escaped their attention. 

The best sphygmograph for ordinary clinical work is that of Dr. 
Dudgeon (see Fig. 61). It is very compact and easy of application. 



Fig. 61. 




Dudgeon's sphymograph 



The expansile pulsation of the artery is communicated by a system of 
levers to a needle, which graphically records the qualities of the pulse 
upon smoked paper. 

Directions for Using Dudgeon's Sphygmograph. 

1. Wind up, by the button, the clockwork contained in the box. 
The clockwork carries the smoked paper under the writing-needle. 

2. See that the patient is in a comfortable position, and have him 
hold toward you either hand with wrist exposed, fingers gently flexed, 
and muscles relaxed. 

3. Apply the instrument by slipping the band over the hand, the free 
end of the band being passed through the retaining clamp. The metal 
box is placed toward the elbow. 

4. Now adjust the instrument by placing the bulging-button which 
connects with the levers directly over the radial artery at its most 
accessible point. 

5. Keep the instrument accurately in place with the left hand, and 
draw the band through the clamp with the right until the writing- 
needle plays freely with each pulsation of the radial artery, then fasten 
the band by screwing up the clamp. 

6. Introduce the smoked paper between the rollers and under the 
writing-needle. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



377 



7. Vary the pressure by means of the thumb-screw, which connects 
with an excentric, until the best apparent amplitude of vibration is ob- 
tained. 

8. Instruct the patient not to move the fingers or hand, and further 
steady them for him with your own right hand. 

9. Start the clockwork by pushing the bar at the top of the clock- 
work box. 

10. Allow the paper to run through, and then stop the clockwork. 

The clockwork is so regulated that five inches of smoked paper pass 
through in ten seconds, so that six times the number of pulsations 
recorded on the paper represents the pulse rate per minute. Each 
instrument, however, should be tested and its time determined. The 
clockwork should be wound up for every other tracing. 

Considerable practice will be required to take a tracing rapidly and 
accurately, in spite of the simplicity of the mechanism. 

Several tracings should be taken at different pressures and compared, 
or, what is better, as suggested by Sausom, stop the clockwork and 
alter the pressure two or three times, so as to have the effects of varying 
pressures on one tracing. 

The technique of sphygmography needs a few words. Smoked paper 
is generally used for the tracings. A paper glazed upon one surface 
and rough upon the other has some advantages. This paper has to be 
cut in strips about seven-eighths of an inch wide and six inches or more 
long. The cutting should be done with care so that the edges are 
smooth and even, otherwise the paper sticks in the instrument and the 
tracing is spoiled. The glazed surface is blackened by holding it above 
the flame of a small piece of burning gum camphor. For convenience 
a strip of tin, bent upon itself at each end, so as to catch and hold 
about an inch of the ends of the paper, may be used to prevent the 
fingers from becoming blackened and to preserve the ends of the paper 
unblackened for memoranda. The blacking should not be too thick, 
otherwise the needle will not plough through it easily, and the white 
line of the tracing will not be distinct. After the tracing has been 
made, the name of the patient, the diagnosis of his disease, the date of 
the tracing, and the amount of pressure employed should at once be 
scratched with a fine-pointed pen upon the blackened surface beneath 
the tracing, or written in ink upon the unblackened end of the paper. 
The tracing is then ready for preservation. This is done by dipping it 
in a solution of shellac or in tincture of benzoin (gum benzoin Sj, 
alcohol fSvj) ; the alcohol evaporates and leaves a smooth, glazed sur- 
face. Dr. Dudgeon recommends as a varnish a solution of gum 
damar 5j, rectified benzoline fSyj. When the tracing is likely to be 
subjected to friction, a second or third coat should be applied subse- 
quently. 

Explanation of the Normal Pulse Tracing. 

With each contraction of the left ventricle a volume of blood is 
forced into the aorta, which distends it, the distending impulse being 
transmitted wave-like to remote arteries. This distending impulse lifts 
the button of the lever sharply upward, forming the so-called percus- 



378 



SPECIAL DIAGNOSIS. 



sion up-stroke, a b. But the distending impulse is exaggerated by the 
system of levers, and having been thrown up too high the lever falls 
by its own weight too low, so that it is again caught and lifted by the 
tidal blood, forming the tidal wave, ode. The gradual descent of the 
lever is again interrupted at efg, forming a wave, called the dicrotic 
wave, due to the recoil of the blood from the closure of the aortic 
valves. 

Fig. 62. 



b 




a b, percussion up-stroke ; a b c, percussion wave ; c d e, tidal wave ; e f g, dicrotic wave ; 
d e f, aortic notch ; / g, diastolic period. 

Interpretation of Pulse Tracings. Sphygmographic tracings 
must be interpreted in accordance with the known peculiarities of the 
patient, his history, and the associated physical signs. 

1. The Amplitude. The height of the percussion stroke varies con- 
siderably in health. It is increased in conditions which bring about 
low tension and rapid systolic contractions of the heart. Hence the 
febrile pulse is usually one of considerable amplitude. It is increased 
also very markedly in aortic regurgitation. Suddenness of systole 
rather than force determines the height of the up-stroke (see Fig. 63). 



Fig. 63. 




Tracing from a case of aortic regurgitation. 



2. Obliquity of the Percussion Stroke. Normally the percussion 
stroke ascends vertically from the base line. A tendency for it to 
incline forward indicates a weak and laboring heart or an aneurism 
interposed between the radial artery and the heart. In the latter case 
there is also a tendency to rounding of the summit of the percussion 



Fig. 64. 




Tracing from a case of aneurism of the aorta. 



wave, and the up-stroke is generally short. There is usually also 
irregularity in successive pulsations, some showing the gradual ascent 
and rounded summit much better than others. Sometimes, however, 
when aneurism exists, there is no evidence of it in the tracing, and 
differences upon the two sides are not always significant (see Fig. 64). 



HEART, BLOODVESSELS, AND MEDIASTINUM. 379 



Disease at the aortic orifice and the intervention of a considerable 
quantity of subcutaneous fat, or of any growth superficial to the vessel, 
may cause a marked obliquity of the percussion stroke. Sausom 
asserts that, such causes excluded, as well as aneurism and organic dis- 
ease of the aorta and its valves, a sloping line of ascent, observed 
under various gradations of pressure, indicates feebleness of the left 
ventricle. He considers it of higher diagnostic value than irregularity, 
which is often neurosal. 

3. Increased Breadth of the Apex of the Percussion Wave. The 
breadth of the apex of the percussion wave indicates the time during 
which the artery is kept full by the systole of the left veutricle. When 
the left veDtricle acts slowly and forcibly the arteries will be kept dis- 



FlG. 65. 




From a case of aortic stenosis, showing increased tension and the pulsus bisferiens. 



tended for a longer time, and this distention will be manifest in broad- 
ening of the apex of the tracing (see Fig. 65). The degree of distention 
of the artery is called the tension, hence a broadening of the apex is 
an evidence of high tension. As the word high does not indicate the 



Fig. 66. 




From a case of mitral stenosis, showing increased tension and some irregularity. 



duration of the tension, Sansom has very properly suggested that we 
should speak of persistent high tension as prolonged tension. This, 
then, is the significance of the broad top of the tracing. 

Prolonged arterial tension occurs when there is a strong heart acting 
slowly, a large volume of blood, or obstruction in the capillary circula- 
tion. (For specific causes, see under Tension.) 

The amount of pressure required to develop the characteristics of a 
pulse, and still more, the amount required to obliterate it, is a good 
index of the degree of tension present. Some pulses, however, appear 
to the touch to be of prolonged tension, but a sphygtnogram does not 
show it. Such cases are often explained by the fact that the heart has 
begun to fail under the strain put upon it by prolonged obstruction in 
the capillaries. There may be regurgitation also from the mitral or 
aortic orifice. 

4. Acute Angle of the Percussion Wave. When the heart's action is 
feeble or sudden, the volume of blood small, or the resistance in the 
capillaries much lessened, the up-stroke of the tracing is vertical, and 
the down-stroke forms an acute angle with it. The dicrotic wave is 
pronounced, and often descends unduly low, sometimes to the base line. 
These are the characteristics of low tension (see Fig. 67). When the 



380 



SPECIAL DIAGNOSIS. 



dicrotic wave springs from a lower level than the base line of the 
tracing it is hyper dicrotic. When the dicrotic wave is wholly effaced 
in the succeeding up-stroke it is monocrotic. 



Fig. 67. 




Low tension with irregularity, from cases of mitral regurgitation. 



While dicrotism is commonly associated with low-tension pulses, it 
is occasionally met with also in high-tension pulses. Sansom says, 
however, that he has scarcely ever observed the conjunction of broad 
summit and marked dicrotism without the patient manifesting the 
signs of failing heart. 

5. Irregularity of the Base Line. This occurs normally in some 
persons as the result of respiration, especially deep breathing. It 
occurs in respiratory diseases also, and in affections causing dyspnoea. 
Decided undulation of the base line, the curves being irregular, occurs 
in tubercular meningitis. 

b\ Differences in the Height of Successive Percussion Waves or in their 
Distance from Each Other. These are written evidences of disturbance 
in the rhythm of the heart. The first expresses irregularity in volume 



Fig. 68. 




From a case of advanced mitral stenosis showing extreme irregularity and intermission. 



of successive beats, and the second irregularity in time. When this 
latter amounts to the omission of a beat it is called intermission. All 
these changes are shown in Fig. 68. 

Auscultation. On examination of the arteries the stethoscope is 
always used. The double stethoscope is preferable, as slight pressure 
only must be made upon the vessels. When the single stethoscope 
is used some diagnostic value obtains by the character of the shock 
that is transmitted to the head. The arteries open to auscultation 
are the carotids when the neck is slightly extended ; the subclavian ; 
the innominate above the sterno-clavicular articulation ; the brachial 
artery in the bend of the elbow, with the arm slightly extended 
and the crural artery just below Poupart's ligament. The normal 
systolic and diastolic heart sounds are heard in the carotid and sub- 
clavian arteries. The systolic sounds may be heard over the abdominal 
aorta, due to tension of the vessels. The diastolic sound is rarely heard 
in this situation. In the other vessels no sounds are heard. Pressure 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



381 



murmur. By pressure with the stethoscope over one of the vessels its 
calibre is modified and a murmur created. It corresponds to the pulse, 
hence is systolic in time, and increases or diminishes in intensity, de- 
pending upon the amount of pressure placed upon it. Just here may 
be mentioned the systolic humming which is heard in children between 
the third month and the sixth year over the fontanelles and sometimes 
over the rest of the head. Osier long ago called attention to the 
murmur and pointed out its lack of significance in the diagnosis of 
hydrocephalus. 

Abnormal Sounds. Abnormal sounds or murmurs are due to 
alterations of the blood, disease outside of the vessels causing pressure, 
and disease of the vessels. Murmurs from disease of the vessels, as the 
aorta, are discussed under the head of arterio-sclerosis or aneurism. 

Murmurs may be propagated into the arteries. A systolic murmur 
created at the aortic orifice may be heard in the vessels of the neck and 
along the aorta. On the other hand, in aortic regurgitation, the dia- 
stolic normal sound in the carotid and subclavian disappears, and the 
diastolic murmur is not heard. 

Double Sounds of the Vessels. Double sounds are sometimes 
heard in the crural artery under the following circumstances. (1) In 
aortic insufficiency ; (2) in mitral stenosis ; (3) in lead-poisoning ; (4) in 
pregnancy. Vierordt is the authority who refers to these conditions 
having been described by Traube, Weil, and others. Duroziez' double 
murmur, heard when greater pressure is used by the stethoscope, occurs 
in aortic regurgitation when there is good compensation. Many authori- 
ties refer to this as a valuable diagnostic sign in this affection. The 
double sound in all instances occurs with large and quick pulse. It is 
probably caused by sudden collapse of the artery and the reflux blood 
current which is possibly an aortic regurgitation. 

Murmurs due to Alterations of the Blood. They are gen- 
erated in anaemia and chlorosis. They are called functional murmurs 
to distinguish them from murmurs due to disease of the vessels. They 
are systolic in time. They are soft and low in pitch, often of a musical 
character. The degree of loudness may vary with the position of 
the patient. They are increased by excitement. The loudness of the 
murmur increases in the course of fevers. Murmurs in the vessels 
apparently of functional origin are sometimes heard. The vessels are 
dilated without actual disease. The increased calibre favors the develop- 
ment of murmur by the creation of a fluid vein. Dilatation of the in- 
nominate artery sometimes takes place, giving rise to a murmur, which 
in loudness and character simulates the murmur of aneurism. A func- 
tional murmur is sometimes heard in the vessels, independent of disease, 
in cases of aortic regurgitation. The murmur is systolic in time. 

Pressure Murmurs. Pressure of the stethoscope, or that caused 
by disease outside of the bloodvessels. When heard over the subclavian 
artery, pressure murmur may be due to adhesions or consolidation at the 
apex of the lung. It is more frequently heard at the left, and may 
be only present during full expansion of the lung. It is due to tempor- 
ary pulling or bending of the artery during deep breathing. When it 
occurs on both sides, it is not of much significance. Murmurs in the 



382 



SPECIAL DIAGNOSIS. 



axillary artery, or in the arteries anywhere, when surrounded by en- 
larged lymphatic glands, are created by their pressure on these struc- 
tures. Murmurs in the thyroid gland have been referred to (see Goitre). 

Murmurs due to Disease of the Arteries. In the aorta the 
murmurs are due to aneurism or atheroma, or both. In the smaller 
vessels both conditions may be present, although atheroma is the usual 
one. The murmur is systolic in time, rough in character, strong, or 
weak. It is associated with other signs of atheroma. 

Percussion. Percussion is applicable to disease of the aorta only. 
The methods by which it is conducted and the results of the examina- 
tion will be considered in the section on Aneurism. 

The Veins. The jugular veins and the cutaneous veins are alone 
open to examination. The femoral and the popliteal vein can some- 
times be examined when the seat of disease. The ophthalmic veins are 
examined by appropriate instruments. 

Inspection. By inspection the degree of fulness of the veins, the 
occurrence of pulsation, and the presence of thrombosis is ascertained. 
Increased fulness is due to obstruction to the flow of blood toward 
the heart. The increased fulness may be general or confined to the 
veins of one side or of one extremity. General Increase in Size. In 
the first instance there is general venous engorgement. The jugular 
veins, both internal and external, are seen to be distended, even in stout 
people. The observation can be better made by viewing the head when 
it is turned to the opposite side from the vein which is under examina- 
tion. The external jugular can always be seen ; the internal jugular 
when engorged. They may also be felt under these circumstances. 
The position of the veins can be more readily distinguished by observ- 
ing their relation to the sterno-cleido-mastoid muscle. The internal j ugu- 
lar vein is seen in the inter-sterno-cleido-mastoid fossa, just behind the 
sterno-clavicular articulation. Here the jugular bulb is seen. When ab- 
normally full it may project beyond the surface. It may be distinct in 
the dorsal posture. Engorgement of the external veins of the remainder 
of the body are not usually so readily observed, because oedema is fre- 
quently associated with it, and indeed such engorgement is generally ac- 
companied by cyanosis, oedema, ascites, and enlargement of the liver and 
spleen. Because of the general fulness, there is dilatation of the right 
heart (which see), particularly that form which succeeds organic disease 
in other portions of the heart. In some instances pressure upon the 
cava, by an aneurism or tumor in the mediastinum, may cause iucreased 
fulness in the veins. Local Increase in Size, or fulness. Local increase of 
fulness of the veins is due to narrowing or closure of the venous trunk 
by pressure or by thrombosis. Here again a mediastinal tumor press- 
ing upon the cava will cause abnormal fulness of the jugulars. In 
thrombosis of the longitudinal sinus, the veins of the skull become dis- 
tended and tortuous. Enlargement of the veins of the arm or leg 
points to compression or thrombosis of the axillary vein or the femoral 
respectively. The enlargement is associated with oedema of the re- 
spective extremity. Enlargement of the superficial veins of the thorax 
is seen in intra- thoracic pressure from tumor or aneurism. Enlarge- 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



383 



merit of the veins of both legs may be due to obstruction of the vena 
cava or both iliac veins. The latter is liable to occur in pelvic tumors. 
When there is engorgement of the portal vein the collateral circulation 
set up is frequently carried on through the abdominal veins. The veins 
are enlarged ; and, in some instances, also the veins about the navel. 
Because of a permanent patulous condition of the umbilical vein the 
crown of veins — caput Medusae — is formed. Enlargement of the veins 
of the extremities, from the causes above mentioned, must not be con- 
founded with the unilateral or bilateral varicosity that occurs after preg- 
nancy, after prolonged intra-abdominal pressure from other causes, or 
in inflammation of the veins which may have occurred in the course of 
septic diseases, as typhoid fever. 

Pulsation of the veins. The circulation in the veins differs from that 
in the arteries. The blood-flow is continuous. It is modified by the 
respiratory movements. The modification is particularly seen in the 
veins of the neck. During inspiration, all of the veins empty rapidly 
w r hile in forced expiration, or with strong effort, as seen in coughing, the 
discharge from the veins is checked and they become full and even 
over-distended. When the fulness of the veins is normal the respiratory 
alterations are not observed, except the swelling that occurs in severe 
coughing, as in whooping-cough. When they are abnormal as from 
right-sided cardiac dilatation (q. v.), they show a corresponding to-and-fro 
swelling, synchronous with respiratory movements. Upon coughing, 
the jugular bulb may appear as a rounded bunch between the heads of 
the sterno-mastoid muscle. The internal jugular may also swell and 
contract. Fulness of the veins is seen during the labored expiration 
of asthma and emphysema. 

Rhythm. Alteration of the rhythm is observed in cases of peri- 
carditis or of mediastino-pericarditis. The vessels are drawn upon 
and bent during the act of inspiration. They swell up at this time and 
empty during the expiration, directly opposite to the normal state. 

The Venous Pulse. The cardiac movements also modify the move- 
ments of the blood in the veins. They cause rhythmical pulsation, 
or the venous pulse. This may be communicated from the carotids 
underneath or occur in the vessels. The so-called true and false pulses 
are thus produced. The true venous pulse is divided into the negative 
and positive pulse, the former being the pulse of health, the latter the 
pathological venous pulse. The negative venous pulse is presystolic 
and can only be seen in the external jugulars. The vein collapses 
during the systole and distends before the systole, hence is presystolic. 
This may be observed by inspection, keeping in view also at the same 
time the apex or the carotid pulse. The systolic collapse occurs quickly. 
The presystolic follows slowly, with an appreciable interval between the 
two. The presystolic distention occurs during the time that the auricle 
is filled with blood ; the collapse occurs when the auricle is empty, that 
is, during the ventricular systole. When the auricle is distended, the 
flow of blood from the veins is impeded and hence the jugulars are 
overfilled. When the auricle is empty the flow of blood from the 
veins is favored, hence the vein collapses (the systole). Sometimes it 
is extremely difficult to recognize the normal or negative venous pulse 



384 



SPECIAL DIAGNOSIS. 



on account of undulations in the veins, produced by the blood-flow and 
transmitted carotid impulse. 

The positive venous pulse is systolic in time. It is pathognomonic 
of tricuspid regurgitation (q. v.). When the right ventricle contracts 
the regurgitant blood-wave is transmitted into the cava through the in- 
competent valves. It appears in the internal jugulars or their bulbs, 
because of the direct course of the innominate and right jugular from 
the cava. Subsequently the left may become affected. If the valve in 
the vein is competent a systolic regurgitant wave ensues there. The 
pulsation of the enlarged bulb is seen in the inter-sterno-cleido-mastoid 
fossa. Usually the valve is insufficient, or rapidly becomes so, and the 
systolic back-wave therefore extends upward. The same wave is trans- 
mitted to the veins of the liver, causing systolic swelling and diastolic 
collapse of the liver. These conditions are produced, as previously 
mentioned, in right-sided dilatation of the heart, providing there is 
moderate force and slowness of the heart's action. When the heart 
becomes very weak and rapid the pulsations disappear. 

The negative, true, or normal pulse is distinguished from the patho- 
logical or positive pulse, and from the transmitted pulsation, by its time. 
Comparison of the apex beat, or the carotid pulse of the opposite side, 
shows the collapse to occur during the systole in health, whereas in the 
other conditions fulness takes place during the systole. The patient 
should hold the breath, as increased respiratory movement will modify 
the venous pulsation. The imparted or false pulse, transmitted from 
the carotids, can be distinguished by stopping the flow of blood by 
means of pressure of the finger in the middle of the neck upon the vein 
after it has been emptied by pressure upwards. If the pulsation is com- 
municated, the vein remains empty in the portion nearest the heart, 
and fills up in the peripheral portion. In the positive pulse the portion 
near the heart is filled. Diastolic collapse has been spoken of under 
the head of Pericarditis. In congenital heart disease the systolic venous 
pulse may sometimes be seen, but is extremely rare. 

In the other affections Quincke has described venous pulse in the 
hand and back of the foot with the capillary pulse in aortic regurgita- 
tion and in anaemia. It is probably only the arterial pulse propagated 
through the capillaries. The systolic true pulse previously described 
may be seen in the veins of the face, in the cutaneous veins of the arm, 
in the internal mammary veins, and in the inferior vena cava. 

Thrombosis of the Veins. This is usually detected by palpation, 
and occurs most frequently in the femoral vein. The vein is trans- 
formed into a firm, round cord, and is distinguished from the artery by 
the absence of pulsation. Thrombosis in these veins and in the iliac 
veins higher up occurs in acute infectious diseases and in the debility of 
the aged. Dropsy in the area of distribution of the veins is perceived. 

Auscultation. In health no sounds are heard. Two conditions con- 
tribute to the creation of a murmur in the veins: 1, change in the 
character of the blood ; 2, dilatation with the occurrence of positive 
venous pulse. 

The Venous Hum. In anaemia and chlorosis, sometimes in healthy 
patients a hum or murmur or buzzing sound is heard over the jugular 



HEART, BLOODVESSELS, AND MEDIASTINUM. 385 

veins. It is louder on the right side than on the left. It is soft and low 
in pitch, and may be musical ; it has been described as humming or whiz- 
zing. It is continuous. For its detection a double stethoscope should 
be used, as pressure increases it, and the patient should not turn the 
head aside. It is increased when this position is taken. The murmur 
is modified by the respiration and by the cardiac action. It is louder 
in deep inspiration when the blood is going more rapidly to the thorax. 
It is also louder in the upright position. It is frequently louder during 
the diastole. The increased loudness at these periods occurs because, 
from the suction action during inspiration and during the diastole, the 
blood is more rapidly drawn toward the heart. The murmur is caused 
by the flow of blood from the narrow jugular into its wider bulb, on 
account of which a fluid vein is produced. Similar murmurs are heard 
in other veins, as in those of the extremities when the anaemia is 
profound. They are then stronger during the diastole of the heart. 

The Data Obtained by Inquiry. 

The Subjective Symptoms of Heart Disease. 

A. Symptoms Referred to the Heart. 1. Pain. While pain 
in the region of the heart may be a symptom of disease of that organ 
or of the pericardium, in the large majority of instances it is due to 
other causes. The physician is frequently consulted by the anxious 
patient on account of pain, other than heart pain, referred to this region, 
or more precisely to the fifth or sixth interspaces on the left side. 
The causes of such pain are various : 1, neuralgia ; 2, pleurodynia ; 3, 
myalgia ; 4, local pleurisy; 5, periostitis. The neuralgias may be asso- 
ciated with points of tenderness, which are usually the seat of the greatest 
intensity of the pain. These points of tenderness correspond with the 
positions at which the nerves have their exit through the fascia to the 
surface, and are found along the sternum, in the course of the mid- 
axilla, and along the vertebrae. The pain is paroxysmal, occurs at 
variable periods of the day, and in anaemic subjects or in the course 
of neurasthenia. It may precede the development of herpes zoster. 
In these cases the exact nature of the pain is not known until the erup- 
tion appears. In gout or diabetes we may have local neuritis, which 
causes neuralgic pain in this situation. 

Pleurodynia, which is thought to be an affection of the pleural nerves, 
is more general. The pain is increased by pressure of the finger-tips, 
although it is not localized. It is relieved by pressure of the whole 
hand. In myalgia, which is seen so frequently in phthisis on account 
of severe coughing, in rheumatism and in debilitated subjects generally, 
the pain is more or less diffuse, interferes more or less with movements 
of the chest, is relieved by uniform general pressure, and is usually 
associated with myalgia in other regions. The pain of pleurisy is 
recognized because it usually inhibits the act of breathing, is associated 
with cough, and friction sounds may be detected. Periostitis. In disease 
of the ribs of the prsecordia the pain is associated with tenderness and 
swelling. One or more of the costo-sternal articulations may be 

25 



386 



SPECIAL DIAGNOSIS. 



extremely tender. The pain and tenderness are due to the periostitis of 
syphilis or to that which follows typhoid fever. In one of my cases the 
rib had to be resected. It may be due to the internal pressure and 
erosion of ribs in aneurism. The same affection may cause neuralgic pains 
in the nerves. Abscess. Pain in this region in rare instances may be due 
to localized tuberculous abscess between the pericardium and the walls 
of the thorax. One such case was under my care. The abscess devel- 
oped secondarily to empyema and occupied the precordial region, 
causing bulging. The pain was intense, and was only relieved after the 
caseatiug pus was removed by incision. 

Pain in the epigastrium is often held to be due to cardiac disease. It 
is usually due to gastralgia, or, as it is sometimes termed, cardialgia. 
It is recognized by the location of the pain and its association with 
gastric symptoms, as flatulency, weight, fulness, and acidity. In gastric 
ulcer the epigas'tric pain is localized, accompanied with tenderness on 
pressure, and increased by food. 

Pain in Disease of the Pericardium. Pain in the region of the heart 
is sometimes due to affections of the pericardium. Pericarditis is the 
most common. While centralized in the heart region, it may radiate 
to the left shoulder and extend down the arm. It is paroxysmal and 
may have some of the characters of angina. It is increased by move- 
ment, by pressure, and by the action of the diaphragm. The patient is 
often obliged to sit up in bed and suffers from orthopncea. A peri- 
cardial friction sound is usually detected. Pain due to disease of the 
aorta. Acute inflammation of the aorta is also the cause of cardiac pain. 
The pain extends along the course of the aorta, may be referred to the 
sternum, and extends along the spine. The pain is severe, causing an 
anxious countenance and an expression of extreme suffering. In gouty 
subjects with atheroma, pain may occur in this situation in paroxysms. 
There is usually valvular disease at the aortic orifice. Similar pain 
occurs in syphilis and in alcoholic subjects, and may be due to malaria. 
It is a visceral neurosis, or a form of neuralgia. 

Pain in the region of the heart is frequently due to aneurism. The 
pain is usually due to pressure of the aneurism upon adjacent struc- 
tures. If the bone is pressed upon and erosion is going on, the pain is 
of a boring character, localized at one point. It has been previously 
referred to. In aneurism alone, without pressure, the pain is of a dull 
aching character, increased by movement, relieved by rest. When 
nerves are pressed upon pain may be acute and of the nature of a neur- 
algia. It may follow the course of the nerves and be associated with 
numbness or sensations of tingling. The long duration of the pain, its 
localization, and its aching character are sufficient to exclude angina 
pectoris. When the pain is unilateral it may be due to pressure of an 
aneurism upon the nerves at their exit from the canal ; the pain extends 
along the course of the intercostal nerves. It is severe and burning, 
but there are no localized points of greater intensity. The pain may 
exteud down the arms, and when the abdominal aorta is affected it may 
extend down the legs. In the course of rupture of the aneurism the 
pain is sudden and sharp. Death, however, ensues quickly, so that the 
pain will rarely be complained of. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



387 



Pain in Disease of the Heart. Three forms are seen : 1, pain due to 
disturbances of the rhythm ; 2, pain due to valvular disease ; 3, pain 
due to angina pectoris. 

Disturbance of the Rhythm. Palpitation, intermission, and irregu- 
larity of the heart occur in the large majority of cases without pain. 
Paroxysms of palpitation are sometimes attended with severe precordial 
pain and distress. This occurs in the reflex palpitation, which, as will 
be seen, is due to disease in other situations; in the palpitation of Graves' 
disease and of ansemia. The palpitation of organic disease is induced 
by exertion. The rapid action of the heart is painful and the throbbing 
is complained of, causing distress. 

While intermission and irregularity may continue without pain at 
times, the patient is conscious of this disturbance of the rhythm and 
complains of the stoppage, which then is attended by distress, sometimes 
amounting to severe pain. This is particularly the case when the heart 
action is tumultuous, as the disturbance of rhythm seen in pericarditis 
and in valvular disease. 

Pain due to Valvular Disease. In disease of the aortic valves pain 
is of more frequent occurrence than in other valvular lesions. It is 
usually complained of in the region of the aorta at the base of the heart, 
and is aggravated by exertion. (See Atheroma.) 

Pain due to Angina Pectoris. Heberden was the first to describe 
the attacks of angina pectoris, which, in its typical form and in association 
with disease of the heart, is not of common occurrence. The pain of 
angina is severe and is associated with the most intense anguish. It comes 
on suddenly, and may occur in paroxysms. The patient realizes that the 
pain is in the heart, and complains of feeling as if the organ were held in 
a vise. From the heart it radiates to the neck and down the arms. It 
particularly extends to the left arm, and may be severe in the wrist or 
in the ends of the fingers. With the pain there is a sense of impend- 
ing death, with sinking and depression. The pain lasts but a few seconds 
or minutes, and during that time the face of the patient becomes pale or 
of an ashen hue, perspiration breaks out on the forehead, the extremities 
become cold, the breathing is short. Prostration usually follows the 
attack, but the precordial distress disappears entirely. The attack may 
occur in patients who are free entirely from organic disease of the heart. 
It is most commonly, however, associated with some lesion. The lesions 
frequently found are disease of the coronary arteries, atheroma of the 
aorta, aortic valve disease, and myocarditis with fatty degeneration. 
It occurs after middle life, and is more frequent in males. It may 
occur without exciting cause, or follow undue exertion, exposure to cold, 
mental excitement, or profound emotion. The points upon which the 
recognition of the nature of the attack can be made are : (1.) The seat of 
the pain. This is usually behind the middle of the sternum, or the 
lower part, and more to the left than to the right. From thence it extends 
to the posterior portion of the axilla or it may radiate up to the neck. 
In some instances it extends to the occiput. Frequently the pain ex- 
tends to the left arm as far as the elbow or even to the fingers. It may 
extend to the abdomen or to the right arm. I have seen it affect both 
arms. It is not influenced by external pressure. (2.) The sense of con- 



388 



SPECIAL DIAGNOSIS. 



striction with the indescribable torture of an intense pain are most 
characteristic. (3.) The respirations are shallow, or even may cease, but 
there is no dyspnoea. (4.) The patient is terrified and restless. (5.) The 
pale face, extremely anxious countenance, the cold sweat on the forehead, 
make a striking picture, which when once seen can never be forgotten. 
(6.) Such extreme depression and sensation of impending death occur in 
no other affection. Particularly characteristic is the immediate relief, 
without hysterical manifestations or dyspeptic symptoms of any kind, 
which follows an attack. (7.) During the attack the frequency of the 
pulse is not much influenced, and the action of the heart may be uniform 
and regular. The tension of the pulse is increased during the attack. 

Some authors refer to various grades of angina, and call all forms of 
precordial pain and oppression, with radiation of the pains to the arms 
and neck, mild forms of angina. Such attacks have often obvious 
exciting causes in disturbance of digestiou and in emotional excite- 
ment. When associated with increased arterial tension and signs of 
arterio-sclerosis they may be of an anginoid nature. The greatest 
difficulty exists in distinguishing them from pseudo-angina. Hysterical 
or pseudo-angina can be distinguished only with extreme difficulty. It 
is likely to occur much more frequently than true angina. One attack 
seems to predispose to others. It occurs in females who present other 
symptoms of hysteria. It occurs usually before forty years of age. The 
attacks are most frequent at night, and may be periodical. They are 
particularly associated with menstrual disorders. The pain is less 
severe and the oppression is not so marked in pseudo-angina; coldness 
of the hands and feet, with the occurrence of syncope, or a general 
feeling of sinking, are common symptoms. The pain is of long dura- 
tion and is associated with great agitation. It is preceded by neuralgia, 
and neuralgic pains persist after the attack. There is low tension, 
feeble second sound and soft arteries. The disease is never fatal. In 
one of my patients, attacks of hysterical haemoptysis alternated with the 
anginal attacks. 

2. Palpitation. In palpitation the patient is conscious of the action 
of the heart. Although it may occur in organic disease, it is more 
frequently due to diseases outside of the heart. 

Symptoms. The symptoms vary in degree. In mild forms the patients 
may complain of a fluttering or a sensation of sinking in the precordial 
region. In the more severe forms the heart beats violently against the 
chest. The arteries throb, the action of the heart is increased, and the area 
of impulse against the chest wall is enlarged and visible. The patient 
complains of distress in the precordial region. The pulse may be in- 
creased to 150. In nervous palpitation, the face becomes flushed, and 
after the attacks large quantities of urine are passed. Sometimes, in 
this form of palpitation, exertion relieves the attack. On examination, 
the sounds are found to be normal, but they are clear and metallic in 
character. The diastolic sounds are greatly accentuated. If anemia is 
present, murmurs due to that condition are increased in intensity. The 
attack may last but a few minutes or continue for hours. 

(a) It is most common in cases in which the nervous system generally 
is in a state of increased excitability. Attacks of it occur at puberty 



HEART, BLOODVESSELS, AND MEDIASTINUM. 389 



and at the menopause. It is very common in hysteria and neurasthenia. 
It follows emotional disturbance. It is more frequent in women. 

(b) It is due to the action of toxic substances, as tobacco, tea and 
coffee, and alcohol. 

(c) From strain and over- exert ion, particularly if associated with ex- 
citement, palpitation may occur and continue for a long period. This 
is the form of irritable heart, described by Da Costa, common in young 
soldiers during the war. 

(d) In valvular disease of the heart when compensation fails, and in 
myocarditis, attacks of palpitation occur. They usually then distinctly 
follow exertion. 

3. Intermission and Irregularity. When the patient feels the altera- 
tion in rhythm, it is usually due to nervous disturbance. In organic 
disease usually it is not experienced by the patient. Although not 
a subjective symptom alone, it may be well to speak of irregularity in 
this connection. 

Arrhythmia is the general term applied to irregularity of the action of 
the heart. When the heart intermits, that is when one or two beats are 
dropped at intervals of half a minnte, a minute, or longer ; when the beats 
are unequal in volume and force, or occur at unequal distances in time, 
the heart's action is irregular. The causes of disturbance of the rhythm 
have been classified by Baumgarten 1 as follows : 1. Central causes in 
the medulla either from organic disease, as hemorrhage or concussion, 
or from psychical influences. 2. Reflex influences, as in dyspepsia and 
diseases of the liver, lungs, and kidneys. 3. Toxic influences — tobacco, 
coffee, and tea are common causes ; various drugs, such as digitalis, 
belladonna, and aconite. 4. Changes in the heart itself. Mural 
changes, as dilatation, fatty degeneration, and myocarditis ; changes 
in the cardiac ganglia ; sclerosis of the coronary arteries. 

It must not be forgotten that both irregularity and intermittency 
may occur in persons otherwise in good health and continue for a long 
period of time without any evidence of arterial or cardiac disease. (For 
the va rieties of arrhythmia see The Pulse.) 

B. Symptoms referred to the Circulation. 1. Pulsation of 
the Arteries. Pulsation of the arteries, especially the carotids, the ab- 
dominal aorta, and the brachial arteries occurs in anaemia and is common 
in emotional disturbances, Such pulsation, as of the abdominal aorta, 
may be reflex from organic disease in the vicinity. Similar localized 
pulsation in the innominate arteries may be mistaken for aneurism. 
The pulsation that attends organic heart disease may be due to hyper- 
trophy of the heart, but is particularly characteristic of aortic regurgi- 
tation. 

2. Hemorrhages. In the description of valvular lesions it will be 
seen that hemorrhage from the lungs occurs quite frequently in disease 
of the mitral valve. The hemorrhage may be due to congestion, to 
actual rupture of the vessels, or to hemorrhagic infarct (see Pulmonary 
Hemorrhage). It may simulate hemorrhage due to tuberculosis. 

1 See Transactions of the Association of American Physicians, vol. iii. 



390 



SPECIAL DIAGNOSIS. 



3. Cyanosis. Cyanosis is a symptom of common occurrence in the 
course of organic heart disease (see page 72). 

4. Dropsy (see page 92). The dropsy of heart disease occurs after 
failure in compensation in the course of valvular disease and in dilata- 
tion of the heart. It may disappear entirely, if the conditions are im- 
proved, or become permanent and progressive. In general, it may be 
said to be distinctly a phenomenon of mitral regurgitation and secondary 
tricuspid regurgitation. It occurs in less degree in mitral obstruction, 
and still less in disease at the aortic orifice. 

C. Symptoms referred to the Lungs. The chief subjective 
symptom is dyspnoea. Dyspnoea, due to disease of the heart, is clin- 
ically divided into (1) dyspnoea that is set up or increased by exertion; 
(2) paroxysmal dyspnoea; (3) orthopnoea; (4) rhythmical dyspnoea, or 
Cheyne-Stokes respiration. The dyspnoea of effort takes place after 
the slightest exertion. In paroxysmal dyspnoea the attack comes on 
without apparent cause. It must be distinguished from the paroxysmal 
dyspnoea of asthma or emphysema. The physical signs of lung disease 
usually point to the latter. The paroxysmal dyspnoea of heart disease is 
attended by more violent efforts of breathing than the physical state of 
the lungs warrants, and the difficulty attends both inspiration and ex- 
piration. Wheezing is not so marked as in forms of asthma. There is 
some obstruction to the outgoing of air, but, on account of air-hunger, 
all the efforts of the patient are used to fill the chest. In paroxysmal 
dyspnoea, if the patient is placed in a comfortable position, the breath- 
ing generally is quieted, provided there is no lung or pleural complica- 
tion. The position does not modify the severe dyspnoea of asthma or 
emphysema. Orthopnoea has been described previously (see page 282). 
(For Cheyne-Stokes respiration see page 239). 

Cough. Cough is of frequent occurrence in heart disease. The 
causes are various. It may be due to pressure upon the bronchus or 
the pneumogastric nerves, as in pericardial effusion. It may be due to 
the congestion of the lungs which occurs in failing compensation. A low- 
grade bronchitis may develop on account of passive congestion, causing 
cough. If hemorrhagic infarcts take place, cough may be present. It 
attends the broncho-pneumonia that follows. Iu the cough that occurs 
from pressure of an aneurism, a metallic brassy cough is created, which 
occurs in paroxysms and may be associated with alterations in the voice. 
The clanging cough may result in the expectoration of blood-tinged 
sputa, which is frequently due to the gradual rupture of the aneurism. 

D. Symptoms referred to the Brain. The symptoms are 
usually due to disturbance of the cerebral circulation, either because 
insufficient blood is supplied to the brain or because improperly 
oxygenated blood is supplied. Vertigo, faintness, and languor are com- 
plained of in the first instance. Dulness, stupor, and moderate delirium 
may occur in the later stages in the second instance. In the course of 
organic heart disease, epilepsy, or epileptiform convulsions may arise on 
account of embolism or thrombosis. Chorea is of common occurrence, 
but bears causal relation to the organic disease. Coma in the course of 
heart disease may be due to hemorrhage into the brain, embolism, or to 
thrombosis. Hemorrhage occurs in patients in whom, at the same time, 



HEART, BLOODVESSELS, AND MEDIASTINUM. 391 



there is usually found hypertrophy of the left ventricle, atheroma of the 
artery and renal disease. Embolism occurs in valvular disease, par- 
ticularly in aortic regurgitation and mitral obstruction. With or without 
coma we may have the occurrence of paralysis for the same reason. 

Thrombosis in the course of heart disease is usually due to disease of 
the bloodvessels rather than disease of the heart itself, although weak- 
ening of the heart, as in dilatation, is a predisposing factor to the 
development of thrombosis. 

E. Symptoms referred to the Alimentary Canal. In the 
course of organic heart disease, dyspepsia and forms of gastritis are of 
common occurrence. Patients complain of indigestion of various 
forms, or of nausea and vomiting. While water-brash and flatulence are 
caused primarily by the condition of the heart, they may in their turn 
more frequently cause symptoms of palpitation and cardiac distress. 
These gastric difficulties are more particularly seen in diseases of the 
auriculo-ventricular valves and are associated with congestion of other 
abdominal viscera. 

F. Symptoms referred to the Throat. The patient may com- 
plain of pain in the throat. This may be paroxysmal, and is sometimes 
said to be due to angina pectoris. Hoarseness or modifications of the 
voice are occasional symptoms of pericarditis. They are of frequent 
occurrence in the course of aneurism due to pressure upon the recurrent 
laryngeal nerves. 

G. Symptoms referred to the Kidneys. The kidneys are 
intimately related with the heart at a distant point in the circulation, and 
are the frequent seat of changes due primarily to disease of the central 
organ of circulation. The changes in the urine will be referred to 
again ; suffice it to say that in the course of mitral and tricupsid disease 
and dilatation, scanty urine, of high color, loaded with urates, containing 
a small amount of albumin, is quite common and indicative of passive 
congestion of the kidney. It may result in cyanotic induration or inter- 
stitial nephritis. On the other hand, the urine may be of low specific 
gravity and pale in color. There may or may not be traces of albumin. 
The change is due to a granular, contracted kidney, which is associated 
with hypertrophy of the left ventricle and arterial sclerosis. Bloody 
urine is usually due to renal embolism when it occurs suddenly in the 
course of organic heart disease. It may be due to the emboli that are 
found in septic endocarditis. Renal disease in all forms may complicate 
disease of the heart. (See Kidney Disease.) 

The Subjective Symptoms of Arterial Disease. 

The patient may complain of an increased amount of blood in a part, 
or of a lessened amount. Thus the symptoms of ansemia in a part, as 
vertigo and giddiness, or of flashes of light, may attract attention. (See 
Cerebral Thrombosis.) All the symptoms of deficient supply of blood 
to the brain may be present. The feet are cold for the same reasons. 
The diseased vessels cause blood to be kept away from the area. Pain 
is common only when atheroma or aneurism is present (q. v.). Throb- 
bing or pulsation is complained of. It may be a striking hysterical or 



392 



SPECIAL DIAGNOSIS. 



neurasthenic feature. The abdominal aorta is frequently thus affected. 
The pulsation may be constant or intermittent. There may be dyspeptic 
symptoms. The pulsation of the carotids may cause abnormal sensa- 
tious in the head, and the beating be a source of extreme annoyance. 

Pericarditis. 

Inflammation of the Pericardium. The inflammation may be 
acute or chrouic. It is also divided according to the nature of the 
inflammation into simple fibrinous inflammation and inflammation with 
effusion. The effusion may be serous, bloody, or purulent, depending 
upon the nature of the inflammation. Pericarditis, either acute or 
chronic, is also divided into primary or secondary pericarditis. The 
primary form is of extremely rare occurrence. Indeed, it may well be 
doubted whether, in common with the inflammations of serous mem- 
branes in general, pericarditis is ever primary, or so-called idiopathic, 
in origin. 

1. Pericarditis may be of local origin by extension from pro- 
cesses which have originated in organs in the vicinity of the peri- 
cardium. It may follow a pleurisy and partake of the nature of 
the primary pleural inflammation. It often attends empyema, either 
from extension of the infection to the pericardium, or from rupture 
into the pericardial sac. It follows all forms of inflammation of the 
mediastinum. Disease of the ribs adjacent to the pericardium may set 
up pericarditis. Inflammations below the diaphragm frequently give rise 
to pericarditis. Peritonitis, when general or local; sub-diaphragmatic 
abscess; suppurative gastritis, with perforation of the stomach; abscess 
of the liver; suppurating hydatid, and other forms of suppuration below 
the diaphragm, also lead to pericarditis. 

2. In Qeneral Diseases. The general diseases which are the cause of 
inflammation of the pericardium are those which usually give rise to 
inflammation of serous membranes. They are : Infectious diseases, 
particularly scarlet fever, measles, erysipelas, and typhoid fever. All 
forms of septicaemia may be attended by inflammation of the peri- 
cardium. Tuberculosis is a frequent cause of pericarditis. Inflam- 
mation of this membrane frequently arises in the course of rheumatism. 
It may occur in the course of the disease, or attend some of the affec- 
tions which are associated with, if not themselves of a rheumatic origin, 
such as acute tonsillitis. In the course of certain dyscrasiae the peri- 
cardium is frequently the seat of inflammation. This is particularly 
the case with scurvy. It occurs also frequently in Bright's disease and 
may be the first manifestation to the patient of this disease. This is 
particularly the case in the chronic form of Bright's disease. It occurs 
in the course of gout. Age. The various forms of pericarditis may 
occur at any age, although that which attends scarlatina and rheumatism 
occurs in early life, while late in life it is an attendant upon chronic 
Bright's disease and gout. 

While rarely an attendant upon diseases of the heart, except as a co- 
incidence, it is said to occur after ulcerative endocarditis, after myo- 
carditis, and during the course of aneurism of the aorta. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 393 

Acute Fibrinous, or Plastic, Pericarditis. This is probably the 
most common form that is seen. It is particularly the variety that 
occurs in the course of Bright' s disease and rheumatism. It may be 
wanting entirely in symptoms. An examination of the heart in the 
routine of duty may reveal its presence by physical signs. In the course 
of either of the above-mentioned diseases in which it occurs secondarily 
it may happen that the temperature rises a little higher than it should, 
or that convalescence does not take place so rapidly as we should expect 
from the amelioration of other symptoms, such as the joint inflamma- 
tions in rheumatism. On examination of the pericardium the friction 
sound is detected. In other instances the patient may complain of pain 
in the region of the heart. It is usually localized in the fourth or fifth 
interspace. It is not very severe and not influenced by pressure. 
Sometimes the pain is complained of at the xiphoid cartilage. In rare 
instances it may resemble angina. The pain and the occurrence of fever 
further call attention to the heart. 

Physical Signs. Inspection. Nothing unusual is observed, al- 
though the heart may be seen to beat more violently against the chest 
wall. The impulse is diffused. By palpation a friction fremitus may 
be detected, due to the rubbing together of the roughened pericardial 
surfaces. It is not always present. It may be felt when the whole 
hand is laid over the prsecordia, or when palpation by the tips of the 
fingers alone is resorted to. It is most marked over the right ventricle, 
particularly in the fourth interspace, and is increased when the patient 
leans forward. 

Auscultation The friction sound is usually present. It may be 
present while the fremitus is absent ; but on the other hand, if the 
fremitus is present we can always hear the friction. It is heard over the 
region where the fremitus is felt. Character. It is a to-and-fro rubbing 
or grating sound; sometimes it is quite high in pitch ; it may be of a 
creaking character. It gives one the sensation of being near to the ear. 
It may be modified by the pressure of the stethoscope aud by the posi- 
tion of the patient. It may be heard in the erect and disappear in the 
recumbent posture. Position. It is localized, and not transmitted 
away from the heart. It may be heard along the course of the sternum. 
It is usually heard in the third or fourth interspace, but may be heard 
as high as the second, adjacent to the sternum in either interspace. 
Sometimes it is heard at the second costal cartilage on the right, rarely 
at the apex. The point of maximum intensity varies with the position 
of the patient. Time. It is both systolic and diastolic. In some 
cases it may be only systolic in time, or it may be of a galloping nature, 
representing three sounds during the cardiac cycle. 

Diagnosis. Acute pericarditis without effusion is not recognized 
generally because it has not been sought for. In the larger number of 
cases, as previously intimated, there have been no indications of disease 
of the pericardium during life. If sought for, however, the diagnosis 
is usually easy. The pericardial friction may be mistaken for an 
organic heart murmur or for pleural or pleuro-pericardial friction. It 
is often difficult to distinguish the to-and-fro friction front the murmurs 
of double aortic disease. If attention is paid to the general and local 



394 



SPECIAL DIAGNOSIS. 



phenomena the mistake is not likely to be made. The location of the 
murmurs in organic heart disease, the direction of the transmission, the 
character of the murmur, the peculiar character of the pulse and the 
secondary effects upon the muscles of the heart, point to the diagnosis 
of a valvular lesion. The pleuro-pericardial friction which simulates 
pericardial friction usually occurs in the course of phthisis or pleuro- 
pneumonia. It is modified by respiratory movement : (1) It may dis- 
appear or lessen notably if the breath is held ; (2) a full expiration 
may cause its disappearance. While it is of cardiac rhythm it is 
modified by the respiratory rhythm, so that on inspiration it is usually 
more marked. The pleuro-pericardial friction is not strikingly modi- 
fied by position. Pleural Friction. This is of respiratory rhythm and 
ceases with cessation of breathing. The pericardial friction persists if 
the breath is held. 

Pericarditis with Effusion. I know of no affection which is more 
frequently overlooked during life than pericardial effusion. This occurs 
because its development takes place without symptoms. In plastic peri- 
carditis we have referred to the occurrence of pain. This may occur 
before the effusion in the latter form, but is usually moderate. As with 
dry pericarditis, however, it may, in rare instances, be very severe, 
anginous in character, and be increased by pressure over the heart or on 
the pit of the stomach. 

The symptoms are usually due to the presence of fluid in the peri- 
cardium. On account of it pressure symptoms arise, and the well- 
known physical signs take place. 

1. General Symptoms. Rarely, however, a few general symptoms 
occur. These are usually cerebral. Delirium, which may be moderate 
or maniacal, has been reported in a number of cases. It must not be 
confounded with the delirium which occurs in the course of acute rheu- 
matism with hyperpyrexia. In addition, choreiform movements have 
been described. They may, however, be of rheumatic origin. Other 
cerebral symptoms, as hemiplegia and convulsive attacks in the course 
of pericarditis, are probably due to an associated endocarditis, causing 
embolism, the endocarditis not having been recognized. In some cases 
albuminuria is found. 

2. The Pressure Symptoms. Dyspnoea is the most common. The 
degree depends upon the amount of effusion. If the latter is large 
there may be extreme orthopnoea ; if the effusion is present for a con- 
siderable time, it may give rise to no symptoms. Dysphagia. In large 
effusions this may occur on account of pressure upon the oesophagus. 
Altered Cardiac Rhythm. The effect of the effusion upon the heart 
is to interfere with its action, which, although usually regular, becomes 
on the slightest exertion or the least excitement, irregular or subject to 
severe attacks of palpitation. The heart's action is increased in fre- 
quency ; when the effusion is very large it may be not only irregular, 
but also intermittent. Aphonia may occur from pressure upon the 
recurrent laryngeal nerve. Cough of an irritative character is some- 
times noted, from pressure upon the veins within the thorax. The 
pulsus paradoxus may be present. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



395 



3. Physical Signs. Inspection. There is bulging of the prse- 
cordia, particularly in children. The ribs and interspaces are promi- 
nent. In adults the interspaces are even with or distended beyond the 
surface of the ribs. The enlargement may extend to the- antero-lateral 
region of the left chest. The large effusion interferes with expansion 
of the lung on the left side, and hence movement is diminished. In 
such cases the epigastrium may be prominent on account of dislocation 
downward of the diaphragm and liver. The apex beat is absent or 
faintly seen dislocated upward and to the left. It may be seen in the 
fourth interspace, or a faint impulse observed in the second and third 
interspaces beyond the mid-clavicular line. 

Palpation. The impulse is feeble aud diminishes progressively as the 
effusion increases. The position of the apex determined by inspection 
is confirmed. The pericardial friction which may have been present 
at first disappears with the effusion. Fluctuation may be detected in 
large effusions. 

Percussion. The area of pericardial dulness is increased. The in- 
crease of area usually is found in all directions, although increase of the 



Fig. 69. 




Percussion dulness in pericardial effusion ; the lower and left margins left undefined, owing to 
their having been inseparable from the dull percussion of the abdomen and of the left pleura. 
(Gairdner.) 

dulness upward and to the left is very common. It may extend as 
high as the second rib. As pointed out by Rotch, dulness in the fifth 
right interspace is common in effusion. The triangle formed by the 
right border of the heart and the right lobe of the liver is dull 
instead of resonant. The dulness in large effusion includes the axillary 
region, so that it may simulate a pleural effusion. The dulness, how- 
ever, does not extend below the eighth rib in this region, whereas, in 
pleural effusion, dulness always extends to the bottom of the pleural 
sac. In pericardial effusion, when it is large, the semilunar space, or 
Traube's line, is obliterated. 

Auscultation. On auscultation the sounds are feeble and distant. 
They may be scarcely heard at all over the prsecordial region. The 
sounds at the base of the heart are diminished in intensity. If a fric- 



396 



SPECIAL DIAGNOSIS. 



tion sound was heard at the beginning it disappears entirely as the 
effusion is poured out. In moderate effusions the friction may be 
heard when the erect posture is assumed. The chauge in the rhythm of 
the heart which attends pericarditis is noted. 

It must not be forgotten that the physical signs, and especially the 
chauge in impulse and the area of precordial dulness, are modified by 
the position of the effusion. Accumulations occur behind the heart or 
above it, and in these situations interfere least with the displacement or 
the enfeeblement of the apex beat. The area of dulness, however, is 
increased upward. In cases of large effusion the compression of the 
lung may cause bronchial breathing to be heard posteriorly or in the 
axillary region. In a case under my care the diagnosis of pericardial 
effusion was readily made, but the enormous effusion so markedly simu- 
lated an effusion into the pleural cavity that both serous cavities were 
believed to contain fluid. Aspiration was performed in the sixth inter- 
space in the anterior axillary line. The fluid was removed from the 
pericardium, as was afterward determined. During life the pressure 
signs of laryngeal stridor, difficulty of deglutition, and extreme dys- 
pnoea, were present. Early vomiting, epigastric pain and tenderness, 
slight delirium, albuminuria, and an excessively weak, rapid pulse 
occurred in the course of the disease. The patient was a male, twenty 
years of age. The effusion was due to tuberculous pericarditis, secon- 
dary to tuberculosis of the bronchial glands. The physical signs were : 
prominence of the prsecordia, bulging of the interspaces on the left side, 
diminished expansion of the left side — anteriorly, laterally, and poste- 
riorly; increased expansion at the extreme apex of the lung. On 
palpation the vocal fremitus was absent below the second interspace in 
front, below the third in the axilla, and diminished below the spine of 
the scapula behind. On percussion there was dulness from the second 
left rib in front to the margin ; from the fourth to the eighth rib in the 
axilla; below the eighth rib, tympany. The dulness extended beyond 
the margin of the sternum on the right side, almost to the right nipple 
line, in the fourth and fifth interspaces. Posteriorly, dulness from the 
middle of the scapula to the base of the thorax, except along the verte- 
brae, where, from the seventh to the ninth rib, there was tympany. The 
physical signs of pericardial effusion on auscultation were marked. In 
the axilla there was absent breathing. There were bronchial breathing 
and bronchophony behind from the spine of the scapula to the base along 
the vertebra?. They were most marked opposite the angle of the scapula 
where the above-noted tympany was recorded. In the mid-scapular line 
the breathing lessened from above downward, and was absent at the base. 
It is seen that the physical signs of pleural effusion were present poste- 
riorly and laterally, due to the enormous effusion. At the autopsy the 
pericardium was found to contain sixty- four ounces of fluid. Pleural 
effusion may be excluded in similar cases by the absence of dulness 
in the axillary region below the eighth rib ; by increase in dulness beyond 
the right edge of the sternum ; and at the same time by the absence of 
signs indicating upward dislocation of the heart. 

The general phenomena that attend pericardial effusion depend upon 
the nature of the primary disease and the character of the fluid. In 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



397 



tuberculous pericarditis, emaciation, irregular fever, sweats and prostra- 
tion ensue. In purulent pericarditis there may be recurring chills with 
a temperature range decidedly intermitting, along with other phenomena 
of purulent accumulation. In a case recently seen the patient was 
extremely debilitated and prostrated on account of pneumonia following 
influenza. He was extremely ansernic, and the blood-count showed 
diminution of red cells one-half without other particular change. Every 
fourth day after a chill the temperature would rise to 103° or 104°. 
A friction sound was detected after the second chill. It disappeared, but 
the physical signs of effusion could not well be made out. From the 
first the heart's action was so weak that the sounds were scarcely dis- 
cernible. At the autopsy four or five ounces of pus were found in the 
pericardial sac, the purulent accumulation in this situation being the 
only lesion to account for the symptoms. 

Diagnosis. Pericardial effusion must be distinguished from dilata- 
tiou of the heart. This is not generally difficult, if the patient has been 
under observation during the development of the disease. The impulse 
is not always absent in dilatation; although feeble and diffuse, the 
expansile shock of the impulse is more distinct than in dilatation. 
Fluctuation may be detected. The area of dulness in dilatation does 
not extend upward except in cases in which the right auricle is en- 
larged. The dulness does not extend downward in dilatation without 
similar dislocation of apex beat or of impulse. The shape of the dulness 
differs. In dilatation the dulness is square in shape ; in effusion it is 
triangular or pear-shaped, with the base downward. In dilatation the 
sounds are accentuated, and are of a valvular character; in effusion 
they are muffled. Dilatation does not cause the pressure symptoms that 
occur in effusion. In pericardial effusion Bamberger's sign is of im- 
portance. When the patient is sitting upright an area of dulness about 
the size of a silver dollar can be marked out at the angle of the scapula. 
Over it, dulness, increased fremitus, and bronchial breathing are made 
out. If the patient leans forward the dulness disappears with the other 
signs of consolidation, to return when he sits upright. 

In pericarditis with effusion, after its absorption the friction sound 
may return again. It is of diagnostic significance to have change of 
rhythm and character of the sound from day to day, or of its degree 
of loudness on movement of the patient. Often it may disappear en- 
tirely and all signs of pericardial inflammation subside. In plastic 
pericarditis and pericarditis with effusion, adhesions to the pericardium 
may take place. 

Effusions into the pericardial sac of serum, of blood, or of air, may 
take place without previous inflammation. 

Hydro-pericardium. This may occur in the course of general 
dropsy from kidney or heart disease. It may not prove fatal of itself, 
but when associated with effusions in the pleural sac, contributes to 
the orthopnoea, on account of which death takes place. Rarely after 
scarlet fever, effusion into the pericardial sac may be the only dropsical 
symptom. The physical signs are those of effusion. It is not attended 
by fever. It is frequently overlooked, because investigation beyond the 
pleura is not made after an effusion into that cavity has been found. 



398 



SPECIAL DIAGNOSIS. 



ELemo-pericardium. This occurs on account of rupture of an aneur- 
ism of the first part of the aorta, of the heart itself, or of the coronary 
arteries. Wounds of the pericardium aud heart cause haamo-pericardium. 
The extension of the ulceration of malignant endocarditis to the surface 
may cause gradual effusion of blood. The physical signs are those of 
effusion. Death usually takes place before there has been time for an ex- 
amination of the patieut sufficient to determine its presence. Rapid 
heart failure due to compression is the cause of death. In the case pre- 
viously referred to above, and in cases of rupture of the heart, the 
patient may live for many hours with dyspnoea and progressive weaken- 
ing of the heart. In tuberculosis and cancer the effusion is frequently 
blood-stained. 

Pneumo-pericardittm. This occurs very rarely, and is due to per- 
foration from without by stab-wound, or perforation from the lung, 
oesophagus, or stomach. A purulent exudation may undergo decompo- 
sition, causing an accumulation of gas. If it arises from perforation 
acute pericarditis is set up. The accumulation of gas causes tympany 
over the movable area of percussion dulness. The most striking sign 
is noted on auscultation. Churning, splashing, or metallic sounds are 
heard, drowning the feeble heart-sounds. Death usually occurs quickly. 

Adherent Pericardium. Chronic adhesive pericarditis usually 
follows the acute form. The physical signs are, on inspection, indrawing 
of the interspaces with systolic contraction of the ventricles ; even the 
ribs are said to be drawn in. This indrawing is most marked at the 
apex, and must not be confounded with the retraction that occurs in the 
third and fourth interspaces with the ventricular systole. At the same 
time that the retreat of the surface takes place, if the hand is placed on 
the heart a systolic shock will be felt. In some cases the systolic move- 
ment is of an undulatory character over the prsecordia. With the 
retraction, the apex is noted to be displaced outward and the area of 
impulse is increased. The increase in area of impulse is due to the 
hypertrophy which always attends adhesion of the pericardium when it 
is universal. After the systole there is frequently felt a quick rebound 
known as the diastolic shock, which is said to be characteristic of peri- 
cardial adhesions. The area of cardiac dulness is increased usually 
upward, extending as high as the first interspace. The area of dulness 
is frequently not modified by respiration, that is, it is not lessened when 
the patient takes a full breath and the lungs expand over the precordial 
region. This is particularly the case when there is pleuritis associated 
with pericarditis, a common association in the large majority of cases. 
On auscultation the signs vary. The sounds are due to hypertrophy or to 
dilatation ; and it must not be forgotten that they frequently arise on 
account of pericardial adhesions. In the former condition the first and 
second sounds are accentuated ; in the latter, a murmur may be heard 
at the apex, loud and systolic in time. 

In pericardial adhesions, Friedreich's sign, collapse of the cervical 
veins, is seen. The collapse of the cervical veins takes place during 
the diastole of the heart. In addition the pulsus paradoxus is signifi- 
cant of the presence of pericardial adhesions, or rather of the dilata- 
tion that succeeds the adhesions. The pulse is small and feeble during 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



399 



inspiration, assuming greater strength during the period of expira- 
tion. In pericardial adhesions the physical signs depend upon the 
condition of the heart muscle at the time of the examination. At 
first we have the physical signs of hypertrophy with retraction of 
the interspaces, particularly at the apex, or the space at the xiphoid 
cartilage. This is particularly the case in young subjects. In the 
later period of the disease the physical signs of dilatation arise, in- 
dicated by increase in transverse dulness, enfeeblement of impulse and 
of sounds, with the development of a murmur at the apex, undulation 
of the veins in the neck, and the pulsus paradoxus. The physical signs 
of associate pleurisy aid in the recognition of adherent pericardium. 
Diminution of the breath sounds, increase in the area of cardiac dulness, 
lessened fremitus in the neighborhood of the heart pointing to pleural 
thickening, are associate evidence. Sansom considers the presence of 
pulmonary tuberculosis of value, as pointing to the occurrence of peri- 
cardial adhesions, for the associate pleural adhesions are likely to be 
attended by tuberculous pericarditis. 

The subjective symptoms of dilatation and hypertrophy of the heart 
are the symptoms of adherent pericardium, and are of the nature of the 
process, which is in excess at the time of the examination. 

Mediastinal Pericarditis is a condition in which the pericardium 
is adherent and thickened, and, with the tissues of the anterior mediasti- 
num, involved in a mass of fibrous inflammation. The symptoms attend- 
ant on this condition are those previously described — pulsus paradoxus, 
collapsing jugular veins during diastole, due to the dragging upon the 
innominate veins and cava by the fibrous adhesions, or to stretching and 
narrowing of the aortic arch by these adhesions. (See Fagge.) 

Endocarditis. 

Endocarditis may be acute or chronic. In either form it is usually 
secondary. The acute form is divided into the simple and so-called 
malignant or mycotic endocarditis. 

Simple Endocarditis. Acute endocarditis rarely occurs primarily. 
It usually occurs secondarily to general morbid processes. The patho- 
logical antecedents are acute rheumatism, tonsillitis, whooping-cough, 
scarlet fever, rarely smallpox and typhoid fever. It is of common 
occurrence in pneumonia and tuberculosis. It is frequent in chorea. 
In the simple form it occurs in septic inflammations and in debilitating 
diseases, as cancer. It may occur in gout and develop in the course of 
Bright' s disease. 

Symptoms. The symptoms of simple endocarditis are scarcely ob- 
served during the early course of the disease. The process is latent, 
and there are no indications of cardiac disease. The physical signs 
alone tell of its presence. Unless these are sought for the disease is 
overlooked. The subjective symptoms are negative. In the course of 
rheumatism or chorea the patient may complain of palpitation of the 
heart; increased frequency and irregularity may be observed. At the 
same time the temperature may increase without increase in the rheu- 
matic symptoms, the rise of temperature usually calling attention to the 



400 



SPECIAL DIAGNOSIS. 



cardiac complication. The rise is usually not marked, and may not 
assert itself during the severity of the disease. 

Physical Signs. On examination a murmur is detected at one of the 
cardiac areas. The murmur is soft, low in pitch, and observes the rules 
as to transmission, depending upon the site of the murmur. Instead of 
a distinct murmur a roughening of the first sound alone may be heard. 
It must not be mistaken for the murmur which occurs at the apex in 
cardiac dilatation or for the murmur which takes place in the course of 
fevers, or the murmur at the aortic or pulmonary areas due to anaemia, 
which, by the way, rapidly ensues in rheumatism and other affections. 

Malignant Endocarditis. This affection develops in the course 
of rheumatism in but few cases only. It is very rare in chorea. It 
differs from simple endocarditis by its rarity in the above affections. 
It occurs more frequently in pneumonia than in auy other disease. It 
arises in the course of erysipelas, septicaemia, puerperal fever and 
gonorrhoea. It may occur in the course of dysentery. It is usually a 
streptococcus infection. 

The Symptoms. The symptoms are due to (1) the local infectious 
inflammation, (2) to emboli, (3) the physical signs. The general symp- 
toms due to the morbid specific process are septic in nature. Four 
groups of symptoms are seen : (1) There may be chills and fever, occur- 
ring in paroxysms daily or at intervals of two or three days, the course 
resembling that of pyaemia. With each chill and febrile rise there are 
profuse sweats. Rapid exhaustion ensues. The fever, instead of being 
distinctly intermittent, may be irregular in type. (2) As septic infection 
arises, a typhoid state, which is of frequent occurrence, sets in. The 
temperature is irregular; extreme prostration, low delirium, sordes, 
subsultus, and all the symptoms of that state arise. (3) Some cases are 
characterized by the relative absence of general symptoms. At least, 
they are not marked, and may be mildly febrile only. The physical 
examination shows the occurrence of the marked endocarditis, attended 
by slight fever. In this group there has usually been chronic heart 
disease preceding the affection. The moderate fever with the physical 
signs may continue over a long period of time. (4) In another class of 
cases the symptoms may be almost entirely cerebral, resembling cerebro- 
spinal or basilar meningitis. 

Diagnostic Features. Of the pronounced and constant symptoms 
that attend the course of malignant endocarditis we have: (1) the occur- 
rence of fever ; (2) the occurrence of the heart symptoms ; (3) the occur- 
rence of emboli. 1. The fever may be intermittent, remittent, or con- 
tinuous. As previously noted, when the latter type is present the 
temperature is high and associated with the typhoid state. The 
petechial rashes and erythema are common, so that, as pointed out by 
Osier, the disease may resemble the eruptive fevers. The sweating is 
profuse, contributing to the profound exhaustion which usually ensues. 
A diarrhoea of septic character occurs when the fever is remittent or 
continuous. In a few rapidly fatal cases jaundice has occurred. 2. 
The heart symptoms may be latent entirely, both subjective and objec- 
tive. Repeated examinations are necessary in some cases to determine 
the presence of a murmur or to decide whether a previously existing 



HEART, BLOODVESSELS, AND MEDIASTINUM. 401 

organic lesion is the seat of an acute process. Variations in the 
character of the murmur from day to day may aid in determining this. 
In organic heart disease with dilatation and failure of compensation, 
irregular fever may occur, followed by embolic phenomena. The 
association of the two conditions points to the nature of the process. 
3. The embolic phenomena are due to escape into the blood current 
of soft vegetations on the valves of the left heart (for the right 
heart is rarely affected), which are carried by the blood stream into 
distant points of the circulation. Emboli occur in the brain, pro- 
ducing aphasia or hemiplegia ; they occur in the retina, causing 
some complaints as to vision, but are more particularly recognized 
by an ophthalmoscopic examination. They occur in the kidneys, 
on account of which bloody urine is passed with renal pain. In 
nearly all cases the spleen is the seat of embolism, and in some 
instances infarctions may take place in this organ alone. The spleen is 
always enlarged, and the development of the infarct may be attended 
with pain and increased tenderness on pressure. Emboli in the skin 
and mucous membranes present the most striking phenomena. The 
hemorrhages underneath the skin are minute, due to the infarcts. They 
are seen in the extremities, but may also be found in the trunk. They 
occur in the mucous membranes, as those of the mouth and tongue. 
They are seen in the bulbar conjunctivae, and in the conjunctivas of 
the lids. 

Diagnosis. When embolic phenomena are present the diagnosis is 
made without much difficulty. The more pronounced general symp- 
toms distinguish it from simple endocarditis. The temperature range, 
the septic and typhoid symptoms, belong to the malignant form. The 
more prolonged cases with moderately continuous fever, which occur 
without primary cause, as puerperal fever, are frequently confounded 
with typhoid fever. This is readily appreciated when the symptoms of 
the two are compared. In both there is fever of a continued type, with 
the symptoms of the typhoid state, including delirium. In both there 
are enlargement of the spleen, diarrhoea, and abdominal tenderness. In 
both there are infarctions, although these are extremely rare in typhoid 
fever, and occur late in the disease. In both there is progressive ex- 
haustion. In endocarditis the onset may be more abrupt. The fever 
does not present the regularity of type that is seen in the development 
of typhoid. In endocarditis there is more oppression and dyspnoea 
early in the course of the disease than in typhoid fever. The 
diazo reaction is not found in typhoid fever before the fifth day, 
but rarely, if ever, in endocarditis. The results of bacteriological ex- 
amination distinguish the two affections. This ought to be of value in 
endocarditis, because the process is usually due to a staphylococcus or 
streptococcus infection ; either micro-organism may be found in any 
suppurations which may possibly be present. 

Malignant endocarditis must be distinguished from cerebro-spinal 
fever and from smallpox of a hemorrhagic form. Reliance must be 
placed upon the local cardiac symptoms and physical signs, and the pre- 
ponderance of these over the other symptoms. Of course the occurrence 
of an epidemic of either and a history of exposure are of service in the 

26 



402 



SPECIAL DIAGNOSIS. 



distinction of the diseases. Examination of the blood excludes the 
forms of malaria which formerly were mistaken for endocarditis. 

Chronic Endocarditis. Chronic endocarditis may follow the 
acute form or develop in the course of atheroma or of endarteritis 
due to alcoholism, the poison of syphilis or of gout. With endarteritis 
the endocardial change may be part of the general degenerative changes 
which occur in the aging process. It may be of dynamic origin, 
often following prolonged heavy muscular exertion, on account of which 
the valves, particularly at the aortic orifice, are put upon a strain. The 
process is slow and insidious, and leads to the changes in the valve seg- 
ments which constitute chronic valvular disease. 

Symptoms. The symptoms of chronic, or sclerotic, endocarditis are 
the symptoms of chronic valvular disease. Insufficiency or obstruction, 
or both combined, take place at the affected valve orifice. The outflow 
of blood is retarded in obstruction. Backward flow, or regurgitation, 
takes place in insufficiency in the opposite direction from the normal 
blood current. When there is obstruction hypertrophy usually takes 
place to meet it. If the obstruction is moderate, and the person re- 
mains in good health, the hypertrophy is sufficient to overcome the 
obstruction. In this manner the effect of the valve lesion is compen- 
sated. On the other hand, when blood is permitted to flow by regurgi- 
tation backward into the cavity, and hence opposite to its usual course, 
it meets at the same time blood flowing to this cavity in the normal 
direction, and the result is overdistention, or overfilling, of the cavity. 
Dilatation ensues, and may persist. If the regurgitation takes place 
suddenly the dilatation continues ; if gradually, as in chronic endo- 
carditis, the dilatation is attended with hypertrophy. Thus, when there 
is regurgitation from the left ventricle into the left auricle, on account of 
incompetency at the mitral orifice, the auricle becomes overdistended 
with blood, for at the same time the chamber is filling with blood from 
the pulmonary veins. This overdistention can only be overcome by 
some hypertrophy. When the latter is not sufficient, backing of the 
blood upon the pulmonary circulation takes place, with the consequences 
hereafter to be mentioned. 

The symptoms of chronic endocarditis are latent if the lesions are 
compensated for ; if not, symptoms of failure in compensation or dila- 
tation of the heart arise. The physical signs are those of chronic 
valvulitis. The character of the signs is dependent upon the lesion of 
the valve that is the seat of disease. 

Myocarditis. 

Myocarditis may be acute or chronic. General myocarditis is always 
acute. The local form may be acute or chronic, depending upon the 
degree of the primary cause. The entire muscle or a portion only 
may be affected. The local variety is usually due to a thrombus in 
the terminal endings of the coronary artery, which cuts off the blood 
supply. The changes are those of myocarditis, to which may be added 
necrosis of small areas and the development of aneurism. Etiology. 
Pathological antecedents of acute general myocarditis are the fevers, 



HEART, BLOODVESSELS, AND MEDIASTINUM. 403 



particularly typhoid fever and typhus fever, pneumonia, diphtheria, and 
septic fevers generally. Chronic myocarditis is usually associated with 
atheroma, one of the causes of which obtains and occurs in the later 
stages of Bright' s disease. (See Atheroma.) The result of myocarditis, 
when acute, is the occurrence of dilatation of the heart or the develop- 
ment of fatty heart, or of aneurism of the heart. Chronic myocarditis 
is followed by the fatty heart, by dilatation, by the so-called fibroid 
heart or fibrous myocarditis, by aneurism. The above facts in aetiology 
are important in diagnosis. 

Symptoms. The symptoms of acute myocarditis are vague. In the 
course of one of the above-mentioned diseases the patient may complain 
of some oppression in the praecordia and suffer from dyspnoea ; attacks 
from syncope may occur, and sighing may be frequent. The pulse 
becomes more rapid and weak, but is usually not irregular. The circu- 
lation is much depressed, the hands may be cold, the face pallid. These 
symptoms may point simply to the extreme exhaustion that follows fever, 
although there is no doubt that some myocarditis exists in all cases, par- 
ticularly if high temperature is present in the course of the fever. In 
many cases no symptoms referable to the heart are complained of, death 
taking place suddenly, in the course of the disease or after it has spent 
its force, on account of acute dilatation or cardiac paralysis. This is 
particularly the case in pneumonia and in the course of diphtheria. In 
the latter affection the sudden supervention of cardiac symptoms, dys- 
pnoea, cyanosis, and cold extremities, may be due to paralysis of the 
heart. Physical Signs. Enfeeblemeut of the heart sounds, with some- 
times increased accentuation of the mitral first sound, is observed. The 
impulse and apex beat are absent or scarcely detected at all. If acute 
dilatation supervenes the area of dulness may be increased. 

The symptoms of chronic myocarditis are obscure and indefinite, and 
in the majority of cases depend upon the secondary changes that have 
taken place in the heart muscle. If there is atrophy of the fibroid 
heart, the pulse is feeble, slow, and irregular. It may be as infrequent 
as thirty or forty beats to the minute. Irregularity is not necessarily 
present, but intermittency is of frequent occurrence. Dyspnoea is com- 
plained of, aggravated by exertion. Attacks of angina pectoris are liable 
to occur. The symptoms of dilatation of the heart may ensue later, with 
the occurrence of oedema, cyanosis, and congestions. In fatty degenera- 
tion of the heart the pulse is increased in frequency, there is cardiac 
irregularity, palpitation, and the occurrence of dyspnoea. These, how- 
ever, are also the symptoms of dilatation, which usually succeeds the 
degeneration. The heart sounds are weak. If dilatation has set 
in a murmur is heard at the apex, with galloping rhythm of the heart. 
In fatty degeneration there is a tendency to syncope, and slowing 
of the pulse rate. Shortness of breath on exertion may occur. Car- 
diac asthma occurs at night, and sighiug and yawning are of fre- 
quent occurrence during the day. Sleeping is usually poor. The 
cerebral functions are in abeyance more or less, the action of the 
mind sluggish ; the patient may have delusions or become maniacal. 
Cheyne-Stokes breathing was formerly thought to be of diagnostic 
significance. 



404 



SPECIAL DIAGNOSIS. 



Chronic myocarditis must be distinguished from fatty overgrowth of 
the heart. This cardiac change is frequently seen in brewers and pub- 
licans, and is usually associated with obesity. The pulse may be feeble, 
the heart sounds weak and muffled. The patients are subject to attacks 
of asthma, and frequently have bronchitis and emphysema. Vertigo is 
of common occurrence. Death may occur during syncope. 

Aneurism of the Heart. 

Aneurism of the valves following endocarditis cannot be recognized 
during life. Aneurism of the walls usually results from chronic myo- 
carditis. The aneurism develops at the apex in the left ventricle. The 
symptoms are indefinite. In rare cases there has been noted marked 
bulging in the region of the apex, and a tumor is made out which may 
perforate the chest wall. A projection beyond the normal line of cardiac 
dulness may be made out by stethoscopic percussion. The symptoms 
are those of myocarditis and of dilatation of the heart. 

Rupture of the heart is one of the causes of sudden death often with- 
out previous symptoms. The accident takes place during exertion. 
Q.uain collected one hundred cases, in seventy-one of which death took 
place without previous warning. In other instances there was a sense 
of anguish and suffocation in the cardiac region. The physical signs of 
slowly developing pericardial effusion may be ascertained if the leakage 
from rupture is slow in progress. 

Chronic Valvular Disease. 

Valvular disease includes valvulitis and valvular incompetency, and 
is recognized by (1) symptoms due to the effect of the lesion upon the 
general circulation ; (2) by the physical signs of a valve lesion ; and 
(3) by the physical signs of alterations in the heart muscle, which 
take place on account of the valve affection. In valvular disease there 
is either obstruction or regurgitation at the orifice which is affected. 
The former is always due to endocarditis in some form, the latter may 
be due to endocarditis, or to inability of the valve segments to close 
the orifice, which has become abnormally enlarged. The lesions cause 
disturbance of the flow of blood through the heart. The symptoms 
differ at different periods of the course of the disease. When the dis- 
turbance in the circulation is overcome by hypertrophy, and compen- 
sation is fully established, there are no symptoms, but only the physical 
signs of the valve lesion and of hypertrophy or dilatation. When 
compensation fails or is broken the symptoms of dilatation of the heart 
arise. In the consideration of valvular disease it is more profitable to 
take up the symptoms of each valve lesion, bearing in mind that two or 
more of the valves may be diseased at the same time, or that both 
obstruction and regurgitation may be present at the same time at the 
same valve orifice. 

Aortic Regurgitation, Insufficiency or Incompetency. 
This may exist for a long period of time without presenting any symp- 
toms. It occurs more frequently in men than in women, and is more 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



405 



common in the later periods of life. It may be due to congenital 
malformation, to acute endocarditis, or, as is most frequently the case, 
to chronic endocarditis, and particularly that form which follows 
strain or undue exertion ; alcoholism and syphilis are also frequent ante- 
cedents of this condition. In rare cases it follows rupture of the valves. 
Relative insufficiency or incompetency is of very rare occurrence. In- 
sufficiency is frequently combined with obstruction. 

On account of insufficiency, or regurgitation, at the aortic orifice the 
blood falls directly into the left ventricle during the diastole. There is 
first a relative diminution in the amount of blood in the artery ; and 
second, an increased amount of blood in the ventricle, because the 
regurgitated column of blood meets the blood from the auricle which 
is filling the chamber at the same time. Dilatation of the left ventricle 
ensues, followed by hypertrophy. Dilated hypertrophy thus arises. The 
heart becomes enormously enlarged. This is one of the conditions in 
which enormous enlargement takes place — so-called cor bovinum. Oc- 
curring at the period of life and from the causes above mentioned, 
more or less sclerosis of the arteries attends this valve lesion. 

The General Symptoms. They may be entirely negative as long as 
perfect compensation exists. This is particularly the case if there is but 
little general arterial sclerosis. Coincident lesions of other valves tend 
to break the compensation. The earlier symptoms are those due to 
arterial anaemia, particularly anaemia of the brain. There are headache, 
dizziness, and flashes of light before the eyes. The patient is of an 
anaemic appearance, and soon begins to suffer from shortness of breath. 
This at first develops upon slight exertion. Palpitation and oppression 
about the chest are complained of, readily excited by undue exertion. 
Pain is a common symptom. It may be complained of in the region 
of the praecordia, is of a dull aching character, and may radiate over these 
regions to the neck and down the arms, particularly of the left side. 
The anginoid pains may be followed by attacks of true angina pectoris. 
The latter are more common in aortic regurgitation than in any other 
valve lesion. 

As compensation fails the dyspnoea increases. It takes place at night 
and compels the patient to sleep in a semi-erect posture in bed. Stases 
occur. Congestion of the lungs takes place, on account of which we 
have cough. Hemorrhage occurs, but not as frequently as in mitral 
disease. (Edema of the feet sets in, but general anasarca is not common. 
(Edema of the feet may be due to anaemia. 

In aortic insufficiency sudden death is of common occurrence. This 
may take place at night during an attack of dyspnoea, or occur suddenly 
upon the slightest exertion, such as straining at stool, or the ascending 
of a height, or walking more quickly than usual. 

The Physical Signs of Aortic Regurgitation. Inspection. The apex 
beat is downward, outward, and to the left. It may be as low as the 
seventh interspace, and as far out as the anterior axillary line. The 
area of cardiac impulse is increased. It occupies the whole praecordia, 
and heaviug of the lower half of the chest may be seen. In young 
subjects there is praecordial bulging. 

Palpation. The impulse is strong and heaving. After compensation 



406 



SPECIAL DIAGNOSIS. 



fails it is indefinite and wavy. A thrill, diastolic in time, may be felt 
with the hand placed about the middle of the sternum. 

Percussion. The area of dulness is increased. The extent is greater 
than that of any other valve lesion, and is more particularly downward, 
and to the left. 

Auscultation. At the second costal cartilage on the right a murmur 
is heard, diastolic in time. This may be its seat of maximum intensity. 
It is transmitted along the course of the sternum toward the apex. In 
some instances the maximum of intensity is greatest at the fourth left costal 
cartilage, or even at the apex. The second sound is absent in the large 
majority of cases. In some instances, however, both murmur and second 
sound may be heard at the same time. Other murmurs also are heard in 
aortic regurgitation, not always due to disease of the aortic valves : 

1. A systolic murmur at the second costal cartilage on the right, 
transmitted into the vessels of the neck, short, rough, and high in pitch. 
It is due to roughening of the valve segments or to atheroma of the 
aorta. 

2. A murmur at the apex, rumbling in character, localized to this 
area, usually presystolic in time. It is the murmur described by Flint, 
who attributes it to flapping of the mitral segments, which during dias- 
tole are not forced back against the heart wall. They remain in the 
blood current and produce relative narrowing. 

3. A systolic murmur in the mitral area, low in pitch, due to dilata- 
tion. This occurs when failure in compensation takes places. 

Examination of the Arteries. Pulsation is more common in the per- 
ipheral vessels in aortic regurgitation than in any other valve lesion. 
The carotids throb, the temporals pulsate, the brachial and radial arteries 
are conspicuous. Pulsation of the retinal arteries is seen by the ophthal- 
moscope, and has often led to the recognition of the disease by the 
ophthalmologist who had been consulted for other conditions. The 
pulsation is of a jerking character ; in the neck it may simulate 
the pulsation of an aneurism. The aorta can be seen and felt at the 
suprasternal notch. The abdominal aorta pulsates vigorously in the 
epigastrium. On auscultation of the arteries double murmurs may be 
heard in the carotids and subclavians, and in rare instances they are 
present in the femorals. (See Pulse.) 

The Capillary Pulse. This is seen beneath the finger-nails, or on the 
surface of the skin, as the forehead, when a line is drawn across it. The 
hyperemia produced on either side of the line alternately becomes red 
and then pale. Capillary pulse also occurs in anaemia, and at times in 
neurasthenia. 

The Pulse. The pulse is significant in aortic regurgitation. The 
so-called water-hammer, or Corrigan's pulse, is observed. The pulse is 
quick and jerking, and after striking the finger immediately recedes. 
It is most marked when the arm is held up. 

Aortic Obstruction. Disease at the aortic orifice causing obstruc- 
tion to the flow of blood is rare. It occurs in the aged and with 
atheroma of the arteries. It causes some diminution iu the amount of 
blood in the peripheral circulation, which causes poor nutrition and the 
development of amemia. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



407 



Symptoms. Anaemia develops, and embolic phenomena may occur 
later. The symptoms may be latent until the occurrence of the latter 
accident. 

On account of the position of the aortic valve, embolic symptoms are 
not uncommon. The emboli are distributed throughout the arterial 
circuit, and may take place in the brain, kidneys, or spleen. When 
the obstruction is pronounced, there is lessened supply of blood in the 
arteries. Cerebral anaemia here takes place, causing dizziness and 
fainting. Sleep is more disturbed than in other valve affections, because 
of the cerebral anaemia. Palpitation and cardiac pain occur, but are 
not so common as in aortic regurgitation. When compensation fails, 
dilatation of the left ventricle ensues, followed by pulmonary congestion 
and stases in the systemic circulation. 

The Physical Signs. There is hypertrophy of the left ventricle. 
Inspection. The apex beat is displaced downward and outward. The 
impulse is strong during the period of hypertrophy. Wheu compensa- 
tion fails the physical signs of dilatation ensue. In many cases, from 
the very first, there may be considerable hypertrophy without visible 
impulse, because of associate emphysema, which is common in old men. 

Palpation. At the base of the heart, and in the aortic area, a thrill, 
systolic in time, may be felt. When present, it is usually very dis- 
tinct, aud is transmitted along the course of the vessels. The impulse 
is slow and heaving, as in hypertrophy. In dilatation it is feeble and 
indistinct. 

Percussion. The area of dulness is increased, in the earlier stages, to 
the left and downward. After compensation is broken, dilatation with 
increased dulness ensues. 

Auscultation. A murmur of maximum intensity at the second costal 
cartilage to the right, systolic in time, transmitted in the course of the 
bloodvessels, is heard. It is usually harsh and loud, and may be musi- 
cal. As the heart weakens, the degree of loudness of the murmur 
lessens and its roughening disappears. It becomes soft and low in 
pitch. The second sound, if there is no regurgitation, is muffled or may 
be absent. The pulse is small and regular. The tension is usually 
increased. 

Diagnosis. A systolic murmur at the aortic orifice may be due to 
aortic obstruction, to atheroma or dilatation of the aorta, ulcerative 
aortitis, or to anaemia. The murmur of aortic stenosis is distinguished 
from the others by its character, by the presence of thrill, by the 
character of the pulse, and by its association with hypertrophy of the 
left ventricle. A murmur due to atheroma of the aorta, particularly in 
the course of renal disease, is also associated with hypertrophy of the 
left ventricle, and the distinction is often difficult or impossible. The 
slowness of the pulse is more characteristic of aortic obstruction. The 
murmur of anaemia is softer and low in pitch. There is no thrill, and 
the left ventricle is not hypertrophied. The anaemic murmurs may be 
heard elsewhere. In atheroma the second sound is usually accentuated, 
and in anaemia it is also intensified. 

Mitral Incompetency or Kegurgitation. The regurgitation 
may be due to disease of the valves from previous endocarditis, which is 



408 



SPECIAL DIAGNOSIS. 



usually of rheumatic origin, or to inability of the segments to close 
the orifice, enlarged on account of dilatation of the cavities. The 
latter occurs in dilatation of the left ventricle under all circumstances, 
and in the weakening of the muscle that occurs in fevers and in anaemia. 
It is thus seen that the murmur of mitral insufficiency is one of the 
most commonly observed of all valve murmurs. It must not be for- 
gotten that insufficiency from disease of the valves and from disease 
of the muscles must, if possible, be distinguished from each other. 
The history of the case is usually essential in determining the diagnosis. 

Disease at the mitral orifice producing insufficiency has more serious 
effects upon the pulmonic and arterial circulation than disease at any 
of the other orifices. These effects must be understood in order to ap- 
preciate the symptoms of mitral incompetency. They are as follows: 1. 
With each systolic contraction the blood flows back, on account of the 
insufficiency, to the auricle, where it soon meets a volume of blood 
coming from the lungs. The combined volumes of blood overdistend 
the auricle. Dilatation ensues, and because of increased work to get 
rid of the increased contents, hypertrophy follows. Dilated hyper- 
trophy of the left auricle is the first effect. 2. A larger amount of blood 
is forced, as a result of the above, from the auricle into the left ventricle; 
dilatation and subsequent hypertrophy of this chamber follow, to re- 
move the fluid. 3. On account of the overdistended auricle, the pul- 
monary veins are not fully emptied during the diastole of that chamber. 
The veins are therefore engorged and interfere with the flow of blood 
through the pulmonary circuit. In consequence of the back-flowing 
of blood, the vessels in the pulmonary circuit are dilated and over- 
distended with blood. The right ventricle is compelled to act more 
vigorously, and even then cannot empty itself freely. Dilatation and 
hypertrophy of the right ventricle ensue. 4. This causes obstruction 
of the flow of blood from the right auricle to the right ventricle; dila- 
tation and hypertrophy of its chambers follow. If perfect compensa- 
tion ensues through hypertrophy of both ventricles, engorgement in the 
lungs may not be observed. Moreover, the left ventricle is allowed to 
send out sufficient blood to supply the wants of the system. This com- 
pensation may continue for years. If it fails, either from increase in 
the valve lesion, or incompetency, or from weakening of the muscle, a 
normal amount of blood is not distributed throughout the aortic area, 
but is thrown back upon (1) the left auricle; (2) the pulmonary cir- 
culation; (3) the right heart; and, finally, the systemic veins. For 
a time the pulmonary circuit will alone be engorged, subsequently 
the systemic veins become congested because of dilatation of the right 
auricle and incompetency of the tricuspid valves. We then have the 
occurrence of the secondary effects of stases upon the various orgaus 
of the body, with cyanotic induration and the development of dropsies. 
Mitral incompetency without disease of the valves is of frequent occur- 
rence in emphysema of the lungs and in Bright's disease, and is a con- 
dition which always attends hypertrophy and dilatation, or may take 
place from various causes (see Hypertrophy and Dilatation). 

Symptoms. As to the general symptoms : In a large number of cases 
perfect compensation may continue throughout a long period of time. 



HEAKT, BLOODVESSELS, AND MEDIASTINUM. 



409 



No subjective symptoms arise nor are there symptoms due to dilatation. 
If compensation is not perfectly effected from the first, or is broken 
suddenly or gradually, the symptoms of dilatation arise. 

In patients in whom compensation remains fairly good we have the 
characteristic appearances of a subject of heart disease. It is to this class 
of patients that the general descriptions of heart disease apply. The face 
is pale and pinched, the lips and ears dusky, the capillaries of the cheeks 
enlarged, the finger-nails clubbed, particularly in children ; shortness of 
breath on exertion may be the only symptom complained of, and this 
may exist for years. Patients, however, are liable to attacks of bron- 
chitis, and may have attacks of pulmonary hemorrhage. Palpitation 
of the heart may occur in this as in other forms of heart disease, and 
from the same cause. 

When the compensation is broken symptoms referable to the heart 
and to engorgement of systemic and pulmonary veins occur. Of the 
former palpitation with a sense of oppression is the most common; 
pain is rare. 

Venous engorgement leads to congestions, cyanosis, and dropsies. 
The lungs are the first to be cougested. Dyspnoea becomes constant as 
well as aggravated by exertion. Cough is present, excited by exertion 
or speaking. With the cough there is bloody expectoration. Cyanosis 
occurs. Congestion of other organs follows. The liver is enlarged ; 
obstruction in the portal area is prominent ; chronic gastritis or gastro- 
intestinal catarrh ensues. The spleen is enlarged ; ascites develops, and 
hemorrhoids and congestion in the rest of the portal area are seen. 
The kidneys are congested ; the urine is scanty, albuminous, and con- 
tains casts and blood corpuscles. At the same time that the internal 
viscera are congested dropsies take place, beginning in the feet and 
extending to the rest of the body. Dropsy may have been present 
in the feet before symptoms of portal congestion ensued. The patient 
may be relieved and compensation continue good for a long time. Fre- 
quent attacks of dilatation of this character may take place, their recur- 
rence being due to lack of care in hygienic matters, or failure in health 
from other causes. Finally, however, the compensation cannot be re- 
stored ; the stases persist ; the dropsies become more marked, and the 
symptoms of chronic cyanotic induration and secondary sclerosis of the 
internal organs follow. It must not be forgotten that this is the chief 
form of organic heart disease seen in children. 

Physical Signs. On inspection, the praecordial area is prominent ; 
the apex beat is displaced to the left and downward, rarely below the 
sixth interspace. It may extend to the anterior axillary line. The 
cervical veins pulsate and are distended. The area of impulse is in- 
creased. 

Palpation. The character of the impulse depends upon the stage of 
the disease at which the case is examined. At the time of full com- 
pensation it is strong and even. When this is broken it is feeble and 
diffuse. A thrill is extremely rare. 

Percussion. The area of dulness is increased to the left. The 
transverse width of the heart is much increased because of dilatation of 
both chambers. The area extends beyond the right margin of the 



410 



SPECIAL DIAGNOSIS. 



sternum to the extent of an inch or more and to the left as far as the 
mid-clavicular line ; sometimes to the anterior axillary line. 

Auscultation. At the apex, the mitral area, a murmur is heard. The 
point of maximum intensity is in this region. It is systolic in time; it 
may replace the first sound entirely. It may be soft and low in pitch, 
or rough, high in pitch, even musical in character. It is transmitted to 
the axilla and the angle of the scapula. In some instances it may be 
heard loudest along the left border of the sternum. The pulmonary 
second sound is accentuated ; the accentuation is loudest in the pulmon- 
ary area at the third left interspace. It may be heard very loud over 
the right ventricle between the parasternal line and the left edge of the 
sternum. The murmur of mitral insufficiency is modified by the posi- 
tion of the patient and intensified after exertion. It may be present 
when the patient is lying down, and disappear in an erect posture. It 
may disappear when the patient is quiet and return after exertion. 
Other murmurs are sometimes heard : 

1. A presystolic murmur, soft or rumbling. 2. When dilatation 
ensues, a low-pitched systolic murmur is heard at the ensiform cartilage 
and at the lower left border of the sternum. It is due to tricuspid 
regurgitation. 

The Bloodvessels. The amount of blood in the arteries is dimin- 
ished. There is notable absence of pulsation of the arteries. The pulse 
at first is full and regular. It is notably small in volume and soft. 
As soon as failure of compensation takes place the pulse becomes irreg- 
ular. The irregularity may be that of time as well as volume. 

Of special diagnostic significance we have the position of the murmur 
and the direction of its transmission ; accentuation of the pulmonary 
second sound ; enlargement of the transverse diameter of the heart due 
to dilatation of both ventricles. 

Diagnosis. This is usually easy if the physical signs are sought for. 
Very often patients are treated for the symptoms that arise from conges- 
tion of the viscera without an examination of the heart having been made. 
We have often seen chronic gastritis or gastro-intestinal catarrh due to 
mitral insufficiency not relieved because the primary lesion had not been as- 
certained. In the same way cardiac cough or dyspnoea may be overlooked. 
It is important in the diagnosis to determine if possible the nature of 
the insufficiency, whether it is due to disease of the valves or to incom- 
petency. As previously mentioned, the history is possibly the only 
means by which a diagnosis can be made. If a mitral murmur ensues 
in old people in whom there has been physical cause for the develop- 
ment of dilatation and hypertrophy, as in emphysema or arterio- 
sclerosis, it is usually due to incompetency of the valve leaflets to close 
the orifice. It must not be forgotten that the mitral area is the seat 
of a number of murmurs due to various causes. (See Auscultation.) 

Mitral Stenosis. Obstruction to the flow of blood from the 
auricle to the ventricle is the result of endocarditis, and particularly the 
endocarditis of early life. It is of much more frequent occurrence in 
Avomen, in contradistinction to aortic disease. As intimated, it is much 
more frequent in young adults and children, because its ^etiological 
factors, rheumatism and chorea, are more prevalent. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



411 



On account of the obstruction of the orifice changes eusue in the 
auricle. These changes depend in a measure upon the nature of the 
lesion. In the so-called buttonhole contraction they are very marked. 
The orifice may be so obliterated in rare cases as to admit only a small 
probe. Dilatation and hypertrophy of the left auricle ensue if the 
valve changes take place gradually. The walls of the auricle are thick- 
ened to three or four times their natural size. On account of the dila- 
tation of this auricle the outflow from the pulmonary veins is impeded, 
which in turn obstructs the circulation of blood through the lungs. As 
a consequence dilatation and hypertrophy of the right ventricle occur. 
As a result of this we have, later on, the occurrence of relative incom- 
petency at the tricupsid orifice with engorgement of the systemic veins. 
The left ventricle does not take part in any changes. It retains 
its normal size, but it may look small in comparison with the right 
ventricle. 

Symptoms. If hypertrophy of the right ventricle ensues, the com- 
pensation may be sufficient to prevent the occurrence of symptoms 
for many years. The disease may exist for a number of years without 
discomfort to the patient. Because of its rheumatic origin endocarditis 
may recur, particularly as the subjects are young, and hence may cause 
danger. If fresh endocarditis occurs embolic symptoms are likely to 
take place. These may take place in the brain particularly, causing 
hemiplegia or aphasia. When failure of compensation takes place the 
symptoms described in mitral incompetency arise. They are the symp- 
toms of dilatation of the heart. These symptoms may recur frequently 
during a long period of years. 

Dropsy, however, is not of as common occurrence as in mitral 
regurgitation. Visceral stases are common when compensation fails, 
and in mauy we find enlargement of the liver continuing over a long 
period. Ascites may in rare cases be the only manifestation of mitral 
obstruction. 

The Physical Signs of Mitral Obstruction are more striking and pro- 
nouncedly diagnostic of the lesion than the physical signs of any other 
form of organic heart disease. As the disease develops in children the 
local deformities are more marked than in adults. 

Inspection. For the latter reason precordial bulging is more promi- 
nent. Because the right ventricle is hypertrophied, the sternum and the 
fifth and sixth costal cartilages protrude. As the left ventricle is small, 
the apex beat is not easily found. It is not usually dislocated, certainly 
not beyond the mid-clavicular line. The impulse is not marked at the 
apex. In the third and fourth interspaces a visible impulse is seen 
along the margin of the sternum. After dilatation, the extent of im- 
pulse diminishes and the veins of the neck become engorged, the blood 
regurgitating into them during the systole. Palpation. In the large 
majority of cases a distinct fremitus or thrill is felt — more marked in 
the fourth or fifth interspace, inside of the nipple. It is usually local- 
ized to a small area, is increased during expiration, and is of a twisting, 
grating or grinding character, usually rough. It is made up of a series 
of small shocks increasing in intensity, culminating in a sudden, sharp 
shock, which occurs at the time of the impulse. The thrill is pathog- 



412 



SPECIAL DIAGNOSIS. 



nomonic and may be present when other signs, as the murmur, are 
absent or indistinct. The cardiac impulse is felt strongest at the lower 
margin of the sternum and in the third and fourth interspaces, in some 
cases even in the second. It is due to enlarged and dilated right ven- 
tricle. 

Percussion. The area of cardiac dulness is increased upward and to 
the right and left of the margin of the sternum. The extent of the 
increase of the area of dulness upward as high as the second rib some- 
times is quite characteristic. 

Auscultation. At the apex or just inside of the position of the apex 
beat, a murmur is heard, its point of maximum intensity distinctly local- 
ized to this situation. It is not transmitted. It is of a churning and 
grinding character, or vibratory and purriug. It is usually high in pitch 
and rough. It occurs synchronously with the thrill and terminates with 
a loud shock that is heard simultaneously with the first sound. It is 
therefore presystolic in time. As has been said of the thrill, so of this 
murmur it may be said that it is the only murmur that is pathogno- 
monic of a special lesion. It indicates narrowing of the mitral orifice. 
The only exception iu which this lesion is absent, and yet the murmur 
is present, is in the class of cases described by Flint, referred to in the 
the section on aortic regurgitation. 

The presystolic murmur may occupy the entire period of the diastole. 
In the large majority of cases it occurs in the latter half only, during 
which the auricular systole occurs. In some instances it is heard in 
the middle of the diastole. 

Associate Murmurs. 1. At the same time a systolic murmur may be 
heard at the apex, soft, and low in pitch. It may be transmitted into 
the axilla. It is usually due to associate mitral regurgitation. 2. At the 
lower portion of the sternum a systolic murmur is heard, due to dilata- 
tion and incompetency at the tricuspid orifice. Murmurs in the aortic 
region are not usually heard. The second sound at the pulmonary orifice 
is usually heard accentuated. It is heard in the second and third inter- 
spaces along the left edge of the sternum ; it may be heard at the apex. 
After compensation is broken other murmurs may be heard, and the 
presystolic murmur changes in character. It may disappear entirely 
and be replaced by a sharp first sound. The short, high-pitched systolic 
shock may continue, although the audible murmur disappears. It dis- 
appears, probably because the left auricle has become weakened. The 
tricuspid murmur continues during this period. The points of dis- 
tinction are (1) the position of the murmur; (2) its localization; (3) its 
peculiar character; (4) the systolic shock which takes the place of the 
first sound ; (5) the thrill; (6) the impulse and increased area of dulness 
upward ; (7) accentuated pulmonary second sound. 

Tricuspid Regurgitation or Incompetency. Structural dis- 
ease at the tricuspid orifice is of extremely rare occurrence. Insuffi- 
ciency is comparatively frequent, and is due to dilatation, with relative 
insufficiency of the valve orifice. It occurs secondarily to destructive 
lung diseases, as emphysema, and cirrhosis, and is secondary to regur- 
gitation at the mitral orifice on account of which stases in the lungs 
have taken place. 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



413 



The Symptoms. The symptoms have been detailed in speaking of the 
mitral valve affections. They are those of obstruction in the pulmon- 
ary circulation and engorgement of the systemic veins. On inspection, 
the physical signs of dilatation of the right heart are seen. An impulse 
in the epigastrium is noted. This is seen especially between the xiphoid 
cartilage aud the left margin of the ribs. Pulsation to the right of the 
sternum may also be observed. There is also pulsation in the second 
and third intercostal spaces. The veins of the neck are also seen to 
pulsate. In addition to the wavy pulsation, regurgitation of the blood 
into the right auricle causes transmission of the pulse wave into the 
veins. The pulsation is systolic in time. It is more marked in the 
right jugular than in the left, and in the external than in the internal 
veins. With the pulsation, regurgitation is readily observed by empty- 
ing the external vein. Place the finger with firm pressure on the 
vein just above the clavicle, move it along the course of the vein in the 
direction of the inferior maxillary bone. The vein is thus emptied of 
blood, and with each systole of the heart it will be seen to fill up from 
below in rhythmical pulsation. In addition to the pulsation of the 
veins they are increased in size. This is more noticeable during the act 
of coughing or when the patient holds the breath in full inspiration. 
In rare instances the pulsation is transmitted to the subclavian and axil- 
lary veins. 

The regurgitant pulsation is transmitted to the inferior vena cava as 
well as to the ascending. The hepatic veins also distend during the sys- 
tole. So-called pulsation of the liver is produced. With the one hand 
on the fifth and sixth costal cartilages and the other over the liver in the 
axillary region rhythmical expansile pulsation may be recognized. It 
is not of common occurrence, but is absolutely diagnostic of regurgi- 
tation at the tricuspid orifice. 

Palpation. By palpation the above conditions are determined. The 
impulse over the lower sternum and in the epigastrium is noted to be 
forcible. 

Percussion. The area of cardiac dulness is increased transversely 
and upward as described in mitral stenosis. It extends often far be- 
yond the right edge of the sternum. 

Auscultation. At the xiphoid cartilage or the lower end of the 
sternum a murmur is heard. It is systolic in time, usually low in 
pitch and is heard loud to the left of the sternum, within an inch of 
the apex, and to the right of the sternum and the outer limits of per- 
cussion dulness. Other murmurs are heard due to the primary organic 
disease. The pulmonary second sound is accentuated. 

Tricuspid Stenosis. Stenosis at this valve orifice is generally of 
congenital origin. In rare instances it may be secondary to lesions in the 
left heart. It is accompanied by dilatation of the right auricle. The 
physical signs are the same as in stenosis at the mitral orifice, except the 
alteration in their position. In some instances a presystolic thrill has 
been observed and with it a presystolic murmur at the lower end of the 
sternum or toward the right of it. The area of dulness is increased as 
in right-sided dilatation. Cyanosis is a most prominent symptom and 
may be very intense. 



414 



SPECIAL DIAGNOSIS. 



Disease of the Pulmonary Valve. Diseases of the pulmon- 
ary valve are extremely rare and are almost always congenital. 

Pulmonary Stenosis. In stenosis of the pulmonary valve a sys- 
tolic murmur and thrill to the left of the sternum in the second inter- 
space are detected. The murmur is not transmitted to the vessels of 
the neck. The pulmonary second sound is weak. The effect on the 
heart is the production of right-sided hypertrophy. 

Pulmonary Insufficiency. The physical signs are due to regur- 
gitation into the right ventricle. The maximum intensity of the mur- 
mur is in the second pulmonary interspace, and it is transmitted down 
the sternum. It cannot be told from aortic regurgitation, except by the 
pulse. 

Combined Valvular Lesions. It must not be forgotten that 
disease causing both obstruction and regurgitation can take place at the 
same time, or that two or more valves may be the seat of disease in the 
same individual. It is not impossible, for instance, to have aortic ob- 
struction and regurgitation, mitral obstruction and regurgitation, and 
tricuspid regurgitation. Aortic obstruction or insufficiency is frequently 
combined with mitral insufficiency. Aortic and mitral insufficiency 
occur together most frequently in children; aortic obstruction and mitral 
obstruction in adults. 

When more than one valve is diseased the detection of the various 
lesions is based upon the time of the murmurs, the position of their 
maximum intensity, and the direction of their transmission. Students 
often experience difficulty here. A systolic murmur may be heard in 
the aortic area and in the mitral area at the same time. If it is 
observed that each progressively weakens as the stethoscope is moved 
toward the middle of the psecordial area it may be inferred that the 
murmur, systolic in time, is due to two lesions. As previously intimated, 
the direction of the transmission of the murmur further aids in the 
diagnosis. 

Enlargement of the Heart. 

Enlargement of the heart is due to hypertrophy or to dilatation. In 
hypertrophy there is increased thickness of the muscular walls. This 
may be general or limited to the walls of one chamber. Hypertrophy 
is further divided into simple hypertrophy, in which the cavity or 
cavities are of normal size, and eccentric hypertrophy, in which, with 
increase in the wall, there is enlargement of the cavities. This is 
hypertrophy with dilatation. The left ventricle is most frequently the 
seat of hypertrophy when one chamber is involved. The cause of 
hypertrophy is obstruction to the flow of blood ; increased work is fol- 
lowed by increased size of the muscle. General hypertrophy, or hyper- 
trophy of the left ventricle, occurs from diseases of the heart itself, or 
from affections of the bloodvessels. 

A. Diseases of the heart. 1 . Disease of the aortic valves. Hyper- 
trophy of the left ventricle always follows. 2. Mitral regurgitation. 
3. Pericardial adhesions. 4. Myocarditis of the fibrous variety. 5. 
Neuroses with overaction and frequent palpitation, as in exophthalmic 
goitre and from the effects of tea, tobacco, and alcohol. In pericardial 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



415 



adhesions and myocarditis, hypertrophy arises because of the inability 
of the heart to do the work expected of it. There is no obstruction in 
the course of the vessels or at the orifices. The struggle to keep up 
causes the hypertrophy. In neuroses there is absence of obstruction, 
but the rapid action causes hypertrophy. 

B. Affections of the bloodvessels which cause hypertrophy are : 1. 
General arterial sclerosis. 2. Increased arterial tension due to the 
contraction of the peripheral arteries, as in Bright's disease, and in 
toxaemias from lead, the poison of gout, and syphilis. 3. Increased 
blood -pressure from prolonged muscular exertiou. 4. Narrowing of 
the aorta from external pressure and from congenital stenosis or the 
development of an aneurism. 

Hypertrophy of the Right Ventricle. In hypertrophy of the right 
ventricle obstruction to the flow of blood throughout the pulmonary 
area is the causal condition. This occurs because of lesions of the 
mitral valve, causing pulmonary stasis ; disease of the lungs, causing 
compression of the bloodvessels, as in emphysema or cirrhosis. It 
occurs if there is disease of the right heart with obstruction of the 
valves. In obstruction at the pulmonary orifice the right ventricle 
undergoes secondary hypertrophy. 

Hypertrophy of the Auricles. Simple hypertrophy of the left auricle 
with dilatation develops in mitral stenosis. Hypertrophy of the right 
auricle occurs in right-sided dilatation with tricuspid regurgitation. 

Symptoms. The symptoms of hypertrophy of the heart are general 
and local. The former are not common. They are due to increased 
force of the circulation through the brain, usually causing congestive 
headaches, with noises in the ears, flashes of light, and flushing of the 
face. 

General symptoms arise in the course of hypertrophy of the left 
ventricle on account of the effect of the increased force upon the vascular 
system. In Bright's disease, for instance, or heightened arterial tension 
from other causes, endarteritis develops in the large vessels on account 
of the strain put upon them. This is seen particularly in the aorta 
and its divisions. Whether atheroma is primary or secondary, its 
presence with hypertrophy of the left ventricle indicates that rupture 
of the vessels somewhere in the periphery may take place. This 
occurs most frequently in the brain, causing apoplexy. 

Locally the patient complains of fulness and discomfort, particularly 
marked when lying down on the left side. In the hypertrophy that 
accompanies the tobacco heart, or the irritable heart of soldiers, there 
may be some pain. The organ may be enormously enlarged without 
the patient complaining of discomfort about the heart. Palpitation is 
not of common occurrence except in neurasthenic subjects. 

Physical Signs. If it has developed early in life, when the ribs 
are soft, the hypertrophy causes prsecordial bulging. The intercostal 
spaces are widened and the area of impulse is much increased. The 
apex is changed in position. The hypertrophy of the left ventricle is 
downward and to the left, extending as far as the axilla. 

Palpation. The impulse is forcible and heaving. If the ear is ap- 
plied over the heart the head is visibly raised with each systole. The im- 



416 



SPECIAL DIAGNOSIS. 



pulse is slow. This slow, heaving impulse distinguishes it from the 
forcible impulse of dilated hypertrophy which is sudden and abrupt. 
Inspection is confirmed as to the position of the apex. In moderate 
hypertrophy the apex extends to the sixth interspace in the mid-clavicu- 
lar line. In large-sized hypertrophy it may extend to the seventh 
interspace. 

Percussion. The area of dulness is increased both upward and 
transversely. It may begin as high as the second interspace and extend 
two inches beyond the left mid-clavicular line and an inch beyond the 
right edge of the sternum transversely. In simple hypertrophy the 
area is ovoid. 

Auscultation. When the valves are healthy, prolongations of the first 
sounds occur. They are also at times duller than in health. The dull, 
prolonged first sounds distinguish hypertrophy from dilatation, in 
which the same sounds are clear and sharp. The second sounds are clear 
and loud. The degree of accentuation depends upon the state of the 
peripheral arteries. If there is heightened tension the second sound may 
be reduplicated. If valvular disease is present the sounds are modified. 

The Pulse. The frequency of the pulse is not modified. It is full, 
regular, and strong. The tension is increased. In dilated hypertrophy 
the pulse is full but soft, and more rapid than in simple hypertrophy. 
When failure of the heart takes place the pulse increases in frequency 
and becomes intermittent and irregular. When valve lesions are present 
the pulse is modified accordingly. 

Hypertrophy of the Right Ventricle. Increased pulmonary tension from 
resistance in the pulmonary circulation may always be looked for. If 
there is complete compensation no symptoms are observed or only those 
of dyspnoea on extra exertion. Hypertrophy of this ventricle persists for 
a long period of time without the grave local changes in the heart or 
secondary changes in the peripheral vessels which occur in left ventricle 
hypertrophy. In dilated hypertrophy, when the dilatation is in excess, 
tricuspid regurgitation takes place, with the development of venous 
stases. Induration of the lungs succeeds the engorgement of the 
capillaries in dilated hypertrophy. When the dilatation is excessive 
pulmonary congestions and apoplexy are associated. 

The Physical Signs of hypertrophy of the right ventricle have been 
partially referred to under the various valve affections. There is bulging 
of the lower part of the sternum and cartilages. The epigastric im- 
pulse in the angle between the ensiform cartilage and the ribs has been 
referred to. The impulse may be in the sixth interspace. The impulse 
is diffuse ; it may extend upward as in mitral stenosis. Cardiac 
dulness is increased toward the right an inch or more beyond the 
border of the sternum. The heart sounds are not much changed 
unless there is dilatation. The tricuspid sound is clear and sharp when 
this occurs. The pulmonary second sound is accentuated and reduplication 
may take place. The radial pulse is small. If there is tricuspid 
regurgitation the physical signs that attend it are present. 

Hypertrophy of the Left Auricle. This is present in mitral stenosis 
but cannot be determined by physical signs, save probably greater 
increase of dulness to the left of the sternum in the second and third 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



417 



interspaces. Hypertrophy of the right auricle with dilatation occurs 
under the same circumstances as hypertrophy of the ventricle. It 
dilates more usually than the left auricle in left ventricle hypertrophy. 
There is iucreased area of dulness in the third and fourth interspaces ; 
abnormal pulsation is sometimes observed in this situation before the 
systole, with the signs of tricupsid regurgitation. 

Diagnosis. The forcible impulse that occurs in nervous palpitation 
of the heart must not be confounded with true hypertrophy, although it 
must not be forgotten that hypertrophy follows neurotic palpitation 
frequently, as in the smoker's heart, or in exophthalmic goitre. The 
enlargement must not be confounded with enlargement of the area of 
cardiac dulness in the precordial region from other causes, such as peri- 
cardial effusion ; aneurism and mediastinal tumor, pushing the heart 
against the chest wall ; disease of the lungs, on account of which they are 
withdrawn from the surface of the heart, as in phthisis or chronic 
pleurisy ; and displacement of the heart from pressure, as in effusion on 
the left side of the chest or disease below the diaphragm. The cause of 
hypertrophy should be ascertained, for when discovered it is a valuable 
aid in the diagnosis. It must not be forgotten that emphysema of the 
lung may mask a considerable hypertrophy of the heart by causing 
diminution of the area of dulness. 

Dilatation of the Heart. Enlargement due to dilatation of 
the heart is common. The condition usually succeeds hypertrophy. 
Thickening of the muscles attends dilatation of the cavities, as in 
dilated or eccentric hypertrophy. The dilatation occurs because of 
increased pressure within the cavities or because of weakening of the 
heart walls, the pressure within being normal. 

1. Increased pressure within the walls is due to an increased amount 
of blood within the chamber from regurgitation or an obstacle to the 
outward flow of blood. Simple hypertrophy occurs first in many cases ; 
in others, hypertrophy with dilatation ; in not a few, dilatation at once 
takes place. In dilatation the chamber does not empty itself during the 
systole. It is seen physiologically after the exertion of ascending a 
great height. It may remain within the bounds of physiological action. 
The dilatation is attended by increased epigastric pulsation, and some- 
times increase in cardiac dulness. The tricuspid valves temporarily 
become incompetent, owing to their safety-valve action. It may con- 
tinue after the acute strain, the heart always showing symptoms of the 
condition, or it may disappear entirely. The excessive dilatation that 
sometimes follows results in heart strain, with the cardiac distress of 
which dyspnoea is associated. Acute dilatation from overdistention and 
paralysis of the heart occurs (see Symptoms). Dilatation occurs in 
all forms of heart lesions which have been previously described. The 
most typical form occurs in aortic regurgitation, when the left ventricle 
becomes the seat of dilatation, and in mitral regurgitation when the left 
auricle becomes the seat of dilatation. 

2. Disease of the heart walls lessening the resisting power precedes 
dilatation, the normal pressure within the cavities being maintained. In 
the myocarditis that occurs in the course of fevers, acute dilatation may 
ensue. It occurs in scarlatinal dropsy, typhoid fever, rheumatic fever, 

27 



418 



SPECIAL DIAGNOSIS. 



and erysipelas. The heart muscle changes in acute endo- and peri- 
carditis, on account of which dilatation may ensue. In anaemia and 
chlorosis the same process may take place. In chronic myocarditis, dila- 
tation takes place at the apex. When pericardial adhesions are present, 
the fibrous overgrowth invades the interstices of the myocardium, weak- 
ening thereby the heart muscle. Dilatation may follow. 

Symptoms. The symptoms of dilatation are the reverse of hyper- 
trophy. When the latter fails, the blood is not expelled from the 
chambers in the systole, so that with the blood that accumulates in the 
diastole the chamber is overdistended. Weakening of the muscle aids 
further in the development of dilatation. As soon as dilatation becomes 
permanent, incompetency of the valves takes place. In obstructive 
heart disease, the left side is first affected. It may be compensated for 
by hypertrophy of the right side. When this fails, venous engorgement 
and dropsy ensue. The symptoms have been described under chronic 
valvular disease. In acute dilatation there is a sudden occurrence of 
dyspnoea. Pain may be complained of in the heart. With the dyspnoea, 
the heart's action increases in frequency. The pulse is rapid, feeble, 
•irregular, and may scarcely be felt at the wrist. 

Physical Signs. Inspection. The apex is displaced to the left, but 
rarely downward, unless hypertrophy precedes the dilatation. The 
impulse is diffused and undulatory in appearance. The apex beat may 
be defined with extreme difficulty. It may be visible when the patient 
leans forward, yet not felt. 

Palpation. With the diffused area of impulse, a quick apex beat may 
be felt — much weakened, however. If the right heart is dilated, the 
true apex cannot be felt because the right heart comes in apposition with 
the surface of the chest. The impulse is seen and felt then to the right 
or left of the xiphoid cartilage, and there is a wavy pulsation along the 
left edge of the sternum in the fourth, fifth, and sixth interspaces. If 
the dilatation is extreme, involving the right auricle, a pulsation at 
the third right interspace close to the sternum may be felt. Tricuspid 
regurgitation is then present. 

Percussion. The area of dulness is increased in the same directions 
as found in hypertrophy if the two coexist. In general, it may be 
said the increase extends outward to the right or left, the direction cor- 
responding to the ventricle affected. It is increased upward along the 
left edge of the sternum in left auricle dilatation. When the whole 
heart is dilated, the increase of dulness is in a transverse direction on 
both sides. The apex is rounded or square, not pointed as in hyper- 
trophy. As dilatation occurs so frequently in emphysema of the lungs, 
the modification of the percussion sound must be remembered. 

Auscultation. The systolic sounds are short and sharp. They are high- 
pitched and resemble the diastolic. The latter may become enfeebled when 
the dilatation becomes excessive. The right and leftfirst sounds may differ 
somewhat in intensity, and reduplication may occur. The sounds may 
be obscured by murmurs. The murmurs are due to previous valve dis- 
ease or to incompetency on account of dilatation. The action of the 
heart is irregular and intermittent. The pulse is correspondingly small. 
In dilatation the alteration of the rhythm is extreme. There may be 



HEART, BLOOD VESSELS, AND MEDIASTINUM. 



419 



embryoeardia or foetal-heart rhythm, in which the first and second 
sounds are alike, and the long pause is shortened. More frequently we 
have galloping rhythm of the heart. It must not be forgotten that as 
dilatation ensues, murmurs of various valve lesions may disappear, par- 
ticularly the murmur of mitral stenosis. On the other hand, in the 
earlier stages particularly, murmurs develop on account of incompetency 
at the auriculo-ventricular orifices, in addition to the primary organic 
murmur. These murmurs in turn may disappear, if the dilatation is 
controlled by careful treatment. 

Congenital Heart Disease. 

Cyanosis is the chief symptom of congenital heart disease. The term 
blue disease aud morbus ccerideus are used as synonyms for this condi- 
tion. The lividity appears in the first week of life. It may be general 
or confined to distant points of the circulation. In extreme grades the 
skin is almost purple. It may vary from time to time, and be intense 
on exertion. The external temperature is below normal. If the child 
remains quiet there may be no symptoms of dyspnoea; dyspnoea and 
cough occur if it is moved about, or on exertion when the child is older. 
The physical development is very poor, the mind is sluggish. Clubbing 
of the fingers and toes takes place to a high degree. The recognition of 
the condition in children is not difficult. If a murmur is found in a 
patient with cyanosis during the early weeks of life, it is due to con- 
genital heart disease. The murmur is usually systolic in time. Hyper- 
trophy occurs in a number of cases. In some instances the murmur is 
absent. 

Diseases of the Arteries. 

Arterial Sclerosis or Arterio-capillary Fibrosis. This 
occurs as the result of wear and tear of life and as the accompaniment of 
age. The time of its onset depends upon the quality of the arterial tissue 
which the individual derived by heredity, and upon the amount of wear 
and tear. It may occur early in life, and entire families may show this 
tendency. Very frequently the sclerosis develops from intoxications of 
the system, on account of which persistent spasm of the small vessels 
is set up ; or blood of an impaired quality is passed with greater 
difficulty through the capillaries, as was taught by Bright. The blood 
tension is raised thereby. The poison of alcohol, of lead, of gout, and of 
syphilis leads to this condition. The poison of syphilis and of gout may 
set up directly an inflammation and degeneration of the arteries. In 
renal disease, arterial sclerosis is of common occurrence. The relation 
to the renal lesion differs. It may be primary or secondary. When 
primary, the morbid cause operates upon the kidneys as well as the 
arteries. When secondary, a morbid poison is retained within the system 
by the diseased kidneys, the action of which is such as to cause periph- 
eral spasm and heightened tension 

Overfilling of the bloodvessels from excessive eating and drinking 
is thought by some to cause arterial sclerosis through constant overdis- 
tention of the vessels. In overwork of the vessels and excessive strain 



420 



SPECIAL DIAGNOSIS. 



there is heightened tension or increased peripheral resistance, producing 
the same effect upon the bloodvessels. The result of the above causes 
is thickening of the intinia of the bloodvessels following upon changes 
in the media and adventitia, and endarteritis deformans occurs in the 
large arteries. 

Symptoms. The symptoms vary. They may be general or local. 
The disease may be present and the patients die from other causes, and 
yet the general arterial system is found to be the seat of extensive dis- 
ease. The local symptoms are due to the local giving way of the vessels 
in one part, as occurs in apoplexy from cerebral hemorrhage, or the 
blocking of the coronary artery, or the rupture of an aneurism. 

Physical Signs. Arterio-sclerosis is recognized by inspection, pal- 
pation and auscultation of the bloodvessels, and by observation of 
the condition of the heart. The bloodvessels that are visible are elon- 
gated aud tortuous. There is visible pulsation. When they are palpated 
the artery is hard ; it cannot be compressed ; it is corded or rounded 
underneath the finger, and readily rolled about. The pulse shows at 
once high tension; the wave is slow in ascent, continues long under- 
neath the finger and subsides slowly. If, in the intervals of the beats 
the vessel remains full, the pulse, as previously noted, cannot be oblit- 
erated. Sphygmographic tracings are characteristic. (See Pulse.) If, 
after pressure on the radial artery the artery beyond can be felt, its walls 
are sclerosed ; whereas if the artery is obliterated beyond the point of 
compression, the hardness and firmness of the pulse are due to vascular 
tension and not to thickened walls. The two conditions should be 
determined. Hypertrophy of the heart occurs early in the course of 
the sclerosis on account of peripheral resistance. The hypertrophy 
involves the left ventricle, and is not attended by dilatation. The apex 
beat is out beyond the mid-clavicular line; the impulse is heaving and 
forcible Very characteristic is the occurrence of the second sound at 
the aortic cartilage. It is clear and ringing ; it is heard in the course 
of the bloodvessels, and is most distinct at or beyond the apex near the 
heart. Right-sided hypertrophy and dilatation are not generally present. 
Auscultation of the larger arteries, as the carotids, the abdominal aorta, 
and feniorals, shows a systolic murmur usually rough and high in pitch. 
All of the above-mentioned conditious may be present, and yet the 
patient remain in good health. The hypertrophy apparently compen- 
sates for the arterial occlusiou. There may be no renal disease, or 
moderate renal cirrhosis may be present, indicated by a transient albu- 
minuria, polyuria, aud hyaline tube casts. The subsequent symptoms 
are due largely to closure of one or more vessels in the peripheral cir- 
culation, to the development of an aneurism or dilatation of the aorta, 
to failure of the hypertrophy of the heart, or to the development of 
renal cirrhosis. 

The blocking of peripheral arteries is due to embolism or thrombosis, 
more frequently the latter, and to rupture of peripheral vessels, or in 
all probability, miliary aneurisms. When occlusion of the vessels takes 
place in arteries which supply the extremities, gangrene may occur. 
Sometimes the occlusion is due to simple narrowing of the vessels alone. 
Gangrene of the feet is frequently seen secondary to bad arteries. If the 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



421 



occlusion takes place in the vessels of the brain, various secondary lesions 
are produced. In more or less general occlusion from sclerosis of the 
smaller arteries acute and chronic softening occur. Hemiplegia, mono- 
plegia, or aphasia may occur temporarily from the same cause, relieved by 
collateral circulation, or permanently from embolism, thrombosis, or 
rupture of the vessels. Rupture of the vessels, hence apoplexy, is 
always due to primary disease of the arteries with, in the large majority 
of cases, miliary aneurisms. If the coronary arteries are blocked, throm- 
bosis with sudden death takes place, or chronic myocarditis, with sub- 
sequent aneurism and rupture, occurs. Angina pectoris, with or without 
thrombosis of the coronary artery, is always associated with arterial 
sclerosis. 

Failure of the hypertrophied heart leads to dilatation with all the 
symptoms as previously described, including dyspnoea, scanty urine, and 
dropsies. The murmur at the apex, due to incompetency from dilata- 
tion, may simulate chronic valvular disease, which, however, may never 
have been present. The sclerosis may advance more rapidly in the 
kidneys than in the other portions of the circulation ; on account of the 
contracted kidney, renal symptoms arise. 

Aneurism. 

A true aneurism is formed of one or more of the arterial coats. It is 
usually fusiform, but may be cylindrical. It may be circumscribed or 
sacculated. The fusiform and the saccular are the forms most commonly 
seen. False aneurism or dissecting aneurism arises from laceration of 
the internal coat of the artery. The blood dissects between the layers. 
It occurs in the aorta. Arterio-venous aneurism is seen when commu- 
nication between an artery and a vein has been set up. If the sac in- 
tervenes it is called a varicose aneurism. Sometimes a communication 
is direct, the vein becoming dilated, tortuous, and pulsating. It is 
known as an aneurismal varix. 

An aneurism may occur in the course of arterial sclerosis from diffuse 
distention of the coats. Its typical form is seen in dilatation of the 
aorta with one or more sacculated aneurisms on its surface. Sacculated 
aneurism occurs from rupture of. the tunica media, independent of gen- 
eral disease of the arteries, and in arterial sclerosis. The most common 
seat is the ascending portion of the aorta It occurs early in the course 
of arterial sclerosis. Such form of aneurism is seen in the smaller vessels. 
Aneurisms also arise after the lodgment of an embolus permanently 
plugging the vessel. The proximal end of the vessel becomes dilated. 

Mycotic aneurism, first described by Osier and exhaustively by 
Eppinger, occurs in malignant endocarditis. The aneurisms are small 
in size and multiple, not generally recognized during life. They arise 
on account of the injury produced by the local infection of bacteria in 
different portions of the vascular system. 

Aneurism of the Aorta. In the thoracic portion of the aorta the 
causes which produce arterial sclerosis are operative — chiefly physical 
overwork, alcohol, syphilis, and gout. In this portion of the aorta it 
may be situated just beyond the aortic ring, at the junction of the 



422 SPECIAL DIAGNOSIS. 

ascending and transverse aorta, in the transverse, or at the beginning 
of the descending portion. The larger aneurisms are at the two bends 
of the aorta. 

Symptoms. The symptoms of aneurism are largely due to pressure 
and depend upon the position of the aneurism and the direction of its 
growth. 

Aneurisms, however, may exist without symptoms or appreciable 
physical signs. Sudden death from rupture may take place in a patient 



Fig. 70. 




Aneurism ot ascending portion of arch of aorta. Tumor in first and second interspaces, 
extending into neck. Portion of sternum atrophied. 

who had been under careful observation on account of concealed aneur- 
ism, the presence of which had not been suspected during life. On the 
other hand, cases occur with characteristic pressure symptoms and with 
no physical signs. Pressure symptoms depend entirely upon the posi- 
tion of the tumor. Aneurisms of the ascending portion of the arch 
cause dislocation of the heart outward, toward the right pleura or for- 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



423 



ward, appearing at the second or third interspace, causing erosion of 
the ribs and sternum. The vena cava is compressed, causing enlarge- 
ment of the veins of the head and arms; the subclavian vein may be 
compressed alone, causing enlargement and oedema of the right arm. 
Localized oedema may result, confined to the thorax (see (Edema). If 
the aneurism is large the inferior vena cava may be pressed upon, caus- 
ing oedema of the feet. The right laryngeal nerve may be involved, 
causing aphonia and dyspnoea. Pain attends the aneurismal process. 
Aneurisms of the transverse portion of the aorta project below, forward, 
or back. When forward, they produce tumors behind the manubrium 
which from pressure cause destruction of bone; growing backward, 
marked pressure symptoms are produced. When the trachea is 
pressed upon it causes dyspnoea and cough, which is paroxysmal (see 
Dyspnoea). The oesophagus may be pressed upon, causing dysphagia. 
The left recurrent laryngeal nerve may be pressed upon, causing par- 
alysis of the corresponding cord, w T ith aphonia (see Larynx). Pressure 
on the bronchus may produce bronchorrhoea and dilatation, which in 
turn, may lead to localized abscess. The growth may extend upward, 
involving the coats of the innominate and carotid arteries on the right 
side, or carotid and subclavian on the left, markedly interfering with 
the pulse of the two sides. Pressure on the sympathetic nerve is likely 
to take place in this situation, with contraction of one of the pupils, 
although at first it is sometimes dilated. The thoracic duct is some- 
times compressed, leading to rapid wasting. In the descending portion 
the pressure signs of aneurism are not so marked. The vertebrae are 
likely to be pressed upon in this situation. The pain, therefore, is most 
intense. The oesophagus and left bronchus are compressed. Dysphagia 
and bronchiectasis, the latter causing bronchorrhoea with subsequent 
gangrene attended by fever, are liable to occur. The cough in bron- 
chorrhoea and the fever, together with emaciation, simulate phthisis, for 
which aneurism is often mistaken. The physical signs of phthisis are 
usually pronounced in this situation, and with the presence of bacilli 
in the sputum, render the diagnosis easy. Rupture takes place into the 
bronchus or into the oesophagus. In one of my cases, which had been 
treated for tuberculosis because of small hemorrhages, with the condi- 
tions above mentioned, death took place from rupture into the bronchus, 
causing sudden profuse hemorrhage. When the aneurism is adherent 
to the oesophagus and slowly ulcerating into it, rupture may take place, 
followed by instantaneous death. The vertebrae may be eroded and 
symptoms of spinal compression arise. 

I once saw an autopsy performed by a medico -legal expert on a case 
of sudden death from hemorrhage. The source of the hemorrhage could not 
be ascertained. There was blood in the stomach. When about to give 
up the search, the oesophagus and aorta were suggested for examination. 
A small aneurism was found which had ulcerated into the gullet, with 
subsequent rupture. In another the aneurism had ruptured into the 
pleural sac, causing internal concealed hemorrhage with death. 

Special Symptoms. While pressure symptoms are the most striking 
symptoms of this affection, pain, which is usually due to pressure, must 
be referred to. It is an important constant symptom. It is sharp and 



424 



SPECIAL DIAGNOSIS. 



lancinating, and may occur in paroxysms. It is more severe and 
constant when bone is eroded by pressure on the vertebrae or the thorax 
in front. Anginal attacks may attend the neuralgic pains just described. 
Pain sometimes follows the course of the nerves, extending down the 
arm or to the neck or along the course of the intercostal nerves. 

If a bone, as the sternum, is perforated, the gnawing pain that 
attends the ulcerative process is relieved. 

Cough. The cough is peculiar. It is paroxysmal and of a 
brazen, ringing character, in many cases indicating its laryngeal 
origin, due to pressure upon the appropriate nerves. It is frequently 
paroxysmal when the pressure is directed upon the windpipe or bronchus. 



Fig. 71. 




Aneurism of ascending and transverse portions of aorta projecting forward, destroying ribs and 
sternum. The skin ulcerated, and gradual external leakage took place. The bleeding continued 
in small amounts for a long time. 

In the former instance the cough is dry, in the latter tracheal and 
bronchial. It is attended by a thin, watery expectoration which, if 
bronchiectasis with fermentation ensues, becomes thick and ropy. 
Dyspnoea occurs more frequently in aneurism of the transverse portion 
due (1) to pressure on the recurrent laryngeal nerves ; (2) to compression 
of the trachea ; (3) to compression of the left bronchus. Marked stridor 
attends the first form. When one of the recurrent laryngeal nerves, 
more particularly the left, is pressed upon there is spasm or paralysis of 
the muscles of the vocal cord, causing hoarseness and loss of voice. 
Laryngoscopic examination should not be neglected, for paralysis of the 
abductor muscles without symptoms may be present. 

Hemorrhage. The hemorrhage may be gradual when there is small 
leakage into the trachea at the point of compression. The amount of 
blood lost is small. It may take place externally (see Fig. 71). Pro- 



HEART, BLOODVESSELS, AND MEDIASTINUM. 425 



fuse hemorrhages producing sudden death occur in rupture into the 
trachea or bronchus and from perforation into the lung. With regard 
to difficulty of deglutition, it may be said that the sound should never 
be passed in suspected cases of aneurism on account of the danger of 
rupture of the sac. 

Clubbed Fingers. In intra-thoracic aneurism clubbing of the fingers 
and incurvation of the nails of one hand are sometimes seen, although 
comparatively rarely. 

Compression and pressure on the sympathetic system of nerves has 
been referred to. In addition to pupillary changes there may be 
pallor of one side of the face. When the pupil is dilated this pallor 
may accompany it on account of stimulation of the vaso-dilator fibres. 
When the cilio-spinal branches of the sympathetic are pressed upon, the 
dilator fibres are paralyzed. If the pupil contracts there is also hyper- 
emia of the side of the face and unilateral sweating. 

Physical Signs. Inspection. In health the position of the aorta 
cannot be recognized during life. Pulsation may be seen at the epi- 
sternal notch in rare instances independently of disease of the aorta, 
particularly in women ; it is due to nervous palpitation. An aneurism 
may exist without any external visible signs. Pulsation may be seen 
at either side of the sternum above the level of the third rib, most com- 
monly in the second interspace on the right side. The impulse may be 
seen alone without visible swelling ; the chest must be viewed from 
different situations in order to detect it. An oblique light falling on 
the surface is sometimes necessary. When the innominate artery is 
involved the pulsation is observed in the neck, above the sterno-clavicu- 
lar junction, or above the sternum. 

With the abnormal impulse, a swelling or tumor is present. It may 
be large enough to press the upper portion of the sternum and adjacent 
ribs forward. In other instances a tumor the size of the half of a 
lemon may be seen along the edge of the sternum. The most frequent 
site is the first and second right or the second left interspace. The skin 
over the tumor, as in the case of which an illustration is given, may 
ulcerate and be the seat of persistent small hemorrhages. The apex beat 
of the heart is displaced downward and outward from pressure. 

If the aneurism is seated in the ascending portion of the aorta just 
beyond the aortic ring a pulsating tumor may be seen in the third inter- 
space at the left edge of the sternum. If in the ascending portion, 
beyond the heart, the tumor is in the first or second interspace along 
the right edge of the sternum. In the transverse portion of the aorta 
the upper portion of the sternum is made to protrude frequently, or the 
tumor projects upward into the fossae of the neck. In the descending 
portion it is in the second or third interspace on the left side. In this 
portion of the aorta a tumor is seen in the left scapular region in rare 
instances. 

Palpation. Palpation must be employed by the usual method ; 
bimanual palpation must also be used, one hand placed upon the 
sternum and the other upon the vertebrae. Moderate pressure should 
be employed. Palpation should also be employed at different periods 
of respiration. At times signs are only yielded at the end of complete 



426 



SPECIAL DIAGNOSIS. 



expiration. It must further be said that palpation must be employed 
with the tips of the fingers and also with the palm of the hand applied 
flatly to the surface. 

By palpation the area and degree of pulsation are determined. If 
the aneurism is large or has perforated, the impulse is expansile and 
heaving in character. The sac may be soft and fluctuating, but 
usually presents considerable resistance. In addition to the systolic 
impulse the diastolic shock is often felt. This is the most conclusive 
physical sign. A thrill is frequently present, systolic in time, usually 
due to dilatation of the arch ; at times, to sacculated aneurism. With- 
out visible tumor, pulsation and thrill may be felt in the suprasternal 
notch, if the head is bent forward so the tissues are relaxed and the 
finger pushed down toward the aorta. When the aneurism is filled or 
filling with clot, the tumor may be seen and felt, but be without any 
impulse transmitted to the hand or thrill felt by the fingers. 

Percussion. Percussion forms the most reliable evidence of the 
presence of an aneurism or aneurismal dilatation in cases in which the 
tumor is not too deep-seated or small in size. (See Cardiac Percus- 
sion.) The area of dulness is increased somewhere in the course of the 
aorta. It may be observed projecting outward at the right edge of the 
sternum when the ascending portion of the aorta is the seat of disease, 
or over the entire upper part of the sternum, extending toward the 
left, when the transverse portion is diseased. It may be observed as an 
extension of cardiac dulness upward in the second and third interspaces. 
Sometimes dulness is detected in the scapular regions, particularly of 
the left side. The percussion toue is flat, and there is marked sense of 
resistance. Percussion must be employed with the patient in the 
upright and in the recumbent posture. The character of the tone and 
the shape of the dulness must be noted at the end of full inspiration 
and of full expiration. 

Auscultatory 'percussion is of the utmost value, and the method of 
percussion taught by Sansom and Ewart must be carefully followed. 
An aueurismal tumor may be present without thrill or murmur, but 
yield signs of dulness on percussion. 

Auscultation. As just stated, murmurs may not always be present. 
They depend upon the amount of fibrin in the sack. When present the 
murmur is systolic in time, heard with maximum intensity usually over 
the abnormal area of impulse or tumor, or over the increasing area of 
dulness. It is transmitted in the directiou of the vessels and may be 
heard loud in the vessels of the neck and along the course of the aorta. 
Often a double murmur is heard, the diastolic sound being due to asso- 
ciated regurgitation at the aortic orifice. The diastolic murmur alone 
may sometimes be heard. Increase in intensity or accentuation of the 
aortic second sound is pronounced. The sound is ringing in character 
and is rarely missed in large aneurisms. 

The Peripheral Vessels in Aneurism. The pulse in the two radial 
arteries may show a marked ditference both in volume and in time. 
The difference may indicate the position of the aneurism. If the pulse 
of the right radial is smaller than the left the aneurism may be in or 
near the innominate artery ; if the opposite, it is near or includes the 



HEART, BLOODVESSELS, AND MEDIASTINUM. 



427 



orifice of the left subclavian. The difference in time may also aid in 
the same way to distinguish the seat. Osier refers to obliteration of the 
pulse in the abdominal aorta and its branches. In one case he could not 
feel throbbing in the aorta and the femorals, although the circulation was 
unimpaired. The aneurism was in the descendiug portion of the aorta, 
and its pulsation was seen in the left scapular region. The sac was 
sufficiently large to act as a reservoir which filled during the ventricular 
systole, and from which the blood poured toward the periphery in a 
continuous stream instead of being intermittent. 

Tracheal Tugging. Tracheal tugging may be obtained in one of two 
ways. By the old method the patient should be sitting or standing, 
while the observer sits or stands to one side, and faces him. With, the 
hand furthest from the patient steadying the head, the observer gently 
but firmly grasps the outer and under surface of the cricoid cartilage 
with the thumb and finger of the other hand, while the head is slightly 
thrown back. The head is then flexed so that the neck is no longer 
stretched. The patient is then told to hold his breath completely, and 
any up-and-down movement of the trachea is immediately transmitted 
to the observer's fingers. One must not mistake the transmitted pulsa- 
tion in the cervical vessels for such movement ; and great care should 
be exercised in seeing that the breathing is entirely stopped. 

In the other, or new method, as proposed and practised by Ewart 
(British Medical Journal, March 19, 1892), the observer stands behind 
the patient, steadying the latter's head against his body, and the cricoid 
is firmly held between the tips of the first or middle fingers. The 
writer, after considerable experience, prefers this second method, on 
account of delicacy of touch, firmness of grasp, and comfort to the 
patient. 

Diagnosis of Aneurism. The special points for diagnosis are : the etio- 
logical factors ; the antecedent pathological conditions, as arterial sclerosis ; 
the occurrence of pain ; the occurrence of pressure symptoms ; and the 
physical signs. These have been sufficiently dwelt upon previously, 
and it is not necessary to consider them again. It must not be forgotten 
that aneurism may be present without diagnostic signs, while on the 
other hand the pressure symptoms may be in abeyance. If one of the 
two is present in the male subject past forty, with a previous history 
of syphilis, gout, alcoholism, or muscular strain, the probability is that 
an aneurism is present. The pressure symptoms always point to some 
form of intra-thoracic disease which may cause this group of symptoms. 
Thus, in cancerous disease of the lymphatic glands, or other tumors 
within the mediastinum, pressure symptoms exactly simulating aneurism 
may be present and also the physical signs of a tumor. The tumor, how- 
ever, rarely projects externally, and still more rarely pulsates. If pul- 
sation is present it is not of the expansile character seen in aneurism, nor 
is there as decided a systolic shock when the ear is placed on the chest. 
By the same method, shock of the heart sounds is observed. These are 
notably lessened or absent in tumors from other causes than aneurism. 
In deep-seated tumors with pressure symptoms the condition of the 
arteries apart from aneurism is of diagnostic importance. If there is 
accentuation of the aortic second sound with hypertrophy of the heart, 



428 



SPECIAL DIAGNOSIS. 



it points to aneurism. The occurrence of tracheal tugging is a valuable 
diagnostic point in favor of the latter. In tumor, and especially cancer, 
there is emaciation and development of a cachexia, which is, as is well 
known, most pronounced in cancer of the oesophagus. Cancer of the 
oesophagus from its frequent point of election near the left bronchus 
often simulates the pressure symptoms of aneurism. 

Aneurism must be distinguished from the pulsation of the aorta 
which is seen in aortic regurgitation. This pulsation is usually asso- 
ciated with dilatation, the latter causing increased dulness, which may 
add further to the confusion. Exaggerated pulsation without dilata- 
tion may, as Bramwell has recorded, be the cause of dulness and pulsa- 
tion over the aorta. The subjects are under forty, neurotic, and usually 
anaemic. 

In the distinction between pulsating empyema and aneurism usually 
there is not much difficulty. Wilson points out that aneurism bears a 
definite relation to the central long axis of the chest. The area of dul- 
ness of the aneurism is circumscribed, and is usually the seat of murmurs 
or other sounds synchronous with the rhythm of the heart. The signs 
of pulsating empyema are usually upon the left side and at a distance 
from the median line. The percussion dulness is at the base of the chest 
and extended. Arterial murmurs are not present. The pulsation is 
influenced by pressure and by respiratory movements. 

In mediastinal cancer we are aided by the discovery of enlargement 
of the glands in the axillary or some other situation, or by a history of 
the growth elsewhere. 

Aneurism must not be confounded with phthisis. The diseased vessel 
may occlude a bronchus, cause collapse and bronchial dilatation, hemor- 
rhage may occur, bronchorrhoea and cough always ensue. Fever is not 
marked, which fact, with tracheal tugging, vascular physical signs, and 
the absence of tubercle bacilli, are favorable to aneurism. 

Diseases of the Mediastinum, 

Inflammation of the mediastinum may be limited to the glands or the 
connective tissue. Moderate inflammation of the glands, lymphadenitis, 
occurs in bronchitis aud pneumonia, particularly if bronchitis is of spe- 
cific origin, as in measles or influenza. It is said that such inflamma- 
tion is of common occurrence in whooping-cough, and may be the 
exciting cause of the paroxysms. DeMussy and Guiteras have found 
physical signs of enlargement characterized by dulness in the upper part 
of the interscapular region in cases of this disease and of influenza. 
Other authorities, as Osier, dispute the possibility of this occurrence, or 
at least of its recognition by physical signs. Tuberculous inflammation 
of the lymphatic glands of the mediastinum may give rise, however, to 
local physical signs. Abscess of the glands cannot be distinguished 
during life. 

Tumors of the Mediastinum. Cancer and sarcoma are the most fre- 
quent forms of tumor of this locality. Hare found the proportion in 520 
cases to be as follows : 134 of cancer, 98 of sarcoma, 21 of lymphoma, 
7 of fibroma, 11 of dermoid cyst, 8 of hydatid cyst, and the remainder 



HEART, BLOODVESSELS, AND MEDIASTINUM. 429 



of lipoma, gumma, aud enchondroma. The tumor is most frequently 
found in the anterior mediastinum when one region alone is affected. 
The disease may be either primary or secondary. In sarcoma the former 
variety is more frequent. Males are chiefly affected, aud the age of 
onset is between thirty and forty. 

The symptoms of mediastinal tumor are chiefly due to pressure. 
Dyspnoea is early and constant, and may be laryngeal, or from pressure 
on the trachea. In some instances, encroachment upon the heart or the 
vessels causes dyspnoea. Again, it may be due to a pleural effusion 
which accompanies the growths. Cough of a peculiar character occurs. 
It is laryngeal, and of a dry, brazen quality. For the same reason 
there may be aphonia. (See Disease of the Larynx.) If the blood- 
vessels are pressed upon, symptoms of obstruction occur dependent 
upon the vessel occluded. CEdema of the upper extremities may occur. 
If the oesophagus is pressed upon there is difficulty in deglutition. In 
some instances the sympathetic uerve is pressed upon, causing hyper- 
emias and pupillary changes. 



CHAPTER IV. 



DISEASES OF THE MOUTH, FAUCES, PHARYNX, AND 
(ESOPHAGUS. 

The Mouth. 

The mouth is affected by comparatively few diseases, most of which 
are dependent upon the influence of micro-organisms. The cavity 
forms a good breeding-place for all forms of organisms, and were it 
not for the secretions and constant cleansing of the mouth by the pas- 
sage of food and its physiological labors, diseases would be very 
common. Indeed, it is possible that such diseases do not take place 
at all unless there is some perversion of the normal secretion which 
destroys its antiseptic or anti-microbic power. We know but little 
specifically concerning the changes in the secretions. Clinically we 
do know, however, that in conditions of poor nutrition, in wasting 
diseases generally, and probably in connection with the rheumatic 
diathesis, there is such change in the secretions as permits patho- 
genic micro-organisms to exercise their influence upon the mucous 
membrane. The result of their action is seen in various forms of 
inflammation. 

Symptomatology. The symptomatology of mouth affections is the 
symptomatology of inflammation. Pain, heat, redness, and swelling 
abound. 

The Subjective Symptoms. 

The subjective symptoms are not characterized by great gravity, 
but they are most annoying. 

Pain. This symptom is most aggravating because it is excited by 
the many functional acts connected with the mouth. It occurs in all 
inflammations and ulcerations except those due to syphilis. It is 
aggravated by food, by movements of the lips, cheeks, or tongue, and 
by attempts to discharge saliva, The absence of pain is observed in 
gangrene. 

Heat. The patient complains of the heat of the mouth iu inflam- 
mations. 

Dryness. This symptom is complained of in fevers and in those 
who are compelled to sleep with the mouth open. It may be a condi- 
tion of itself, as the following shows. 

Dry Mouth. Hutchinson first described a condition of the mouth 
in which dryness was the chief complaint. The secretions are sup- 
pressed entirely, the tongue red and dry, the mucous membrane of the 
cheeks and palate smooth, shining and dry. Functional movements 
are very difficult. The majority of the cases are in women in whom 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



431 



the general health is always impaired. It is thought to be of central 
origin by Hayden, on account of which the secretion of the salivary and 
buccal glands is modified. A moderate amount of dry mouth occurs 
in fevers. It is also symptomatic of chronic gastritis, and may occur 
in diabetes. 

The Objective Symptoms. 

The objective symptoms are determined by inspection and palpation. 
By such research the color of the parts of the mouth is observed, 
and changes in temperature, and in the size and shape (swelling) are 
ascertained. The teeth, gums and tongue are also examined. 

Color. The normal redness of the mucous membrane may be in- 
creased or lessened in hue. Pallor is associated with anaemia. Increased 
redness attends inflammation, and with it the temperature is raised. 
The mucous membrane is yellow in jaundice, bluish in cyanosis. Both 
of the latter changes may be observed to greater advantage under the 
tongue. The mucous membrane is the seat of pigmentation in Addi- 
son's disease and in argyria. In the former, small oval purplish spots 
are seen. They must not be confounded with the pigmented spots 
common after stomatitis in negroes. Eruptions occur in the mouth 
and may precede external eruptions. This is notably so in measles. 
In this affection the eruption is seen on the hard and soft palate twenty- 
four hours before the development of the rash. In smallpox and 
chickenpox the vesicles are seen. 

Shape. Swellings are seen usually from disease of structures about 
the mouth. The floor of the mouth is invaded by glands underneath or 
swelling of the cellular tissue. Bone diseases and some teeth affections 
cause swellings. The dental arch must be observed. Increase in height 
of the arch is due to adenoid disease or to the habit of thumb-sucking in 
childhood, much more likely the former. 

Fcetor. The odor imparted to exhaled air is peculiar in mouth- 
affections. It may be a simple foetor or of a metallic or gangrenous 
odor. Foetor attends all inflammations; it is more pronounced in ulcer- 
ative and mercurial stomatitis. In the latter it may be metallic. 

Salivation. Increased flow" of saliva occurs in all inflammations 
unless attended by high fever. It may be constantly discharged by the 
patient or dribble in a continuous stream. (See Saliva.) 

Secretions of the Mouth. The saliva is derived from the par- 
otid, submaxillary and sublingual glands and from the mucous glands 
within the mouth. The mouth should be washed with warm alkaline 
solution and afterward with cold water, in order that the saliva obtained 
may be perfectly pure. After the washing the glands may be stimulated 
by the application of dilute acid on a glass rod. The normal amount that 
is secreted in twenty-four hours varies from two to three pints. It is 
of a light bluish color, or is colorless. It is somewhat stringy. On 
standing, two layers form in a conical glass, the upper clear, the lower 
cloudy. The reaction of saliva is alkaline. 

Microscopic Examination. The following formed elements are ob- 
served : 1. Salivary corpuscles of the appearance of, but larger and 
more granular than a white corpuscle. 2. Epithelium. The squamous 



432 



SPECIAL DIAGNOSIS. 



variety derived from the mouth is seen. The cells are large in size and 
of polygonal shape. 3. Fungi. In health the mould and yeast fungi 
are seldom found. In disease they are present in large numbers ; fission 
fungi are met with in great numbers, both in health and in disease. In 
health small and large colonies of micrococci are found along with 
abundant bacilli. Miller has studied the micro-organisms of the mouth 
carefully and exhaustively (see The Dental Cosmos), both by microsco- 
pical examination and culture methods. The following are found to be 
pathognomonic : (1) The leptothrix buccalis ; (2) vibrio buccalis : 
(3) spirochete dentium ; (4) micrococcus tetragenes ; (5) the micro- 
coccus de la rage ; (6) the micrococcus of septicemic sputa ; (7) the 
bacillus of decaying teeth, three varieties of the staphylococcus ; 
(8) the bacillus crassus sputigenus ; (9) the bacillus salivarius septicus 
and bacillus septicus sputigenus. 



Fig. 72. 




Buccal secretion. (Eye-piece III., obj. Reichert, 1/15, homogeneous immersion ; Abbe's minor, 
open condensers.) Friedlander's and Gunther's method. (Von Jaksch.) 

a, epithelial cells ; b, salivary corpuscles ; c, fat drops ; d, leucocytes ; e, spirochete buccalis ; 
/, comma bacilli of mouth ; g, leptothrix buccalis ; h, i, k, different fungi. 

Of course in the saliva the thrush fungus, actiuomyces, the tubercle 
bacillus and the bacillus of diphtheria are found. It must not be for- 
gotten that the diplococcus pneumoniae or micrococcus lanceolatus, 
which is the specific cause of pneumonia, is found in the saliva in 
health. It is also called the bacillus sputi septicsemici. 

Chemical Examination. The chemical characters of the secretion 
depend upon the activity of the different glands. The saliva contains 
a trace of albumin, found by heating ; a ferment which changes starch into 
sugar; mucin; and sulpho-cyanide of potassium occasionally. In dis- 
ease, as the quantity is diminished rather than increased, examinations 
have rarely been made. In ptyalism the saliva should be collected after 
rinsing the mouth frequently, especially after eating. The reaction is 
found to be alkaline and of low specific gravity, 1002 to 1006. Albu- 
min is tested for by the usual methods. The sulpho-cyanides are 
detected by a solution of the chloride of iron. When this is added to 
the fluid a bright red color appears which does not disappear with heat; 
a similar color may be obtained by the same test from the saliva in 
opium poisoning, due to the precipitation of meconic acid. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



433 



Sugar is tested for by methods used in the examination of the blood 
for this substance. The diastatic ferment is detected by adding 5 c.cm. 
of saliva to 50 c.cm. of starch solution, placing the mixture in a warm 
chamber or a water bath heated to 40° C. After an hour's time the fluid 
will show the presence of grape sugar. Nitrites are detected by adding 
a little of the saliva to a mixture of starch paste, iodide of potassium, 
and dilute sulphuric acid. If the nitrites are present a blue color 
results. 

Saliva in Disease. Increase and diminution in the amount of saliva 
will be referred to. In catarrhal stomatitis the secretion is increased. 
It is acid and contains epithelium in excess. In ulcerative stomatitis 
it is also increased, is of a dark brown color, foetid and alkaline. It 
contains degenerated epithelium, leucocytes, blood corpuscles and many 
forms of fungi. It is increased in pregnancy, in rabies and glosso-labio- 
laryngeal palsy. I have seen it in excess in the convalesence of typhoid 
fever. It is increased by the internal use of jaborandi. 



Fig. 73. 




O'idium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Robin.) 

The reaction becomes acid in diabetes, gout, rheumatism, and mer- 
curial poisoning. Urea may be found in cases of nephritis, particu- 
larly in uraemia. There is no sugar in diabetes. Fenwick has 
investigated the changes in the sulpho-cyanide of potassium in disease. 
By a scale of colors he was enabled to compare the saliva in which 
sulpho-cyanide of potassium had been detected in health with the 
saliva in various diseases. He believes that the amount of this ingre- 
dient is indicative of the degree of functional activity of the organs 
of nutrition. It is increased in acute inflammation and in the earlier 
stages of cancer and ph'thisis ; in acute congestion of the liver from 
stimulants or food excess ; and in rheumatism, gout, and the convalesence 
of typhoid fever. Where the power of the nutritive organs is dimin- 
ished the sulpho-cyanide is lessened, as in late phthisis and cancer, the 
later stages of chronic diarrhoea and dysentery, chronic catarrhal jaun- 
dice, in ascites, and in the passive congestion of the abdominal viscera. 
Fenwick believes tedious recovery and frequent relapses will occur if 
this element is found in excess in acute rheumatism. 

Thrush. The fungus peculiar to this disease is found. Saliva is 
increased ; it is usually acid. The disease is characterized by the for- 

28 



434 



SPECIAL DIAGNOSIS. 



mation of small patches on the mucous membrane, which in a few days 
coalesce and form a mass which may cover the entire mouth and extend 
to the fauces. Before coalescing they are firmly adherent. Subse- 
quently they loosen. On microscopical examination, in addition to 
epithelial cells, leucocytes, and unorganized elements, the characteristic 
parasite is seen. It is in ribbon shape, composed of long segments 
containing often highly refractive nuclei at either end of the segment. 
The parasite varies in length, but is made up of many segments which 
are shorter toward the extremity. The segments vary in length. 
They are homogeneous. When mounted in glycerin they are readily 
seen. Spores are also seen. 

The Leptothrix Bucccdis. The latter is seen in ribbon-like bundles . 
composed of various segments. They stain bluish-red in potassic iodide 
solution. It is most frequently seen in the tartar of the teeth. 



Fig. 74. 




Leptothrix buccalis from the gums at edges of teeth, a, the filaments separated ; 
b, masses of filaments. X 350. 

The Gums. The color and consistence is inquired into. The 
former changes with changes in the mucous membrane of the mouth, 
in inflammations and ulcerations, and in certain metallic poisonings. 
The gums swell and grow spongy in inflammations. 

The Gingival Line. In cases of tuberculosis a red line at the junc- 
tion of the gums and the teeth is frequently seen. At one time it was 
thought to be of diagnostic value. It is seen, however, in other 
cachectic conditions, as carcinoma, and at times in diabetes. 

The Gums in Scurvy. In scurvy the gums are swollen and 
spongy. They bleed easily, and usually are streaked with blood. 
Ulcers form along the teeth line. There is not much foetor of the 
breath. In mild cases the inflammation may be limited to the gums of 
four or five teeth only. The gums about teeth that are decayed are 
usually the seat of the most marked inflammation. 

The Gums in Lead-poisoning. In chronic lead-poisoning a blue line 
appears on the gums and margins of the teeth. The line is preceded 
by a row of separate black dots occupying the seat of the papillse of the 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 435 



mucous membrane. It does not always extend along the entire margin, 
but may be limited to a few front teeth in either the upper or lower 
jaw. In the more advanced cases there is some salivation and sweetish 
metallic taste in the mouth and metallic fcetor of the breath. 

The Teeth. In all diseases of the gastro-intestinal tract it is im- 
portaut to investigate the state of the teeth. Cases of indigestion are 
often due to defective mastication rendered so by decayed teeth. Caries 
of the teeth may cause headaches or neuralgias, near or remote (see 
Headache), and may explain many cases of foul breath. Pitting of the 
surface of the teeth, and thinning of the enamel in transverse grooves, 
are held by some to be due to mercury. It is no doubt true that 
infantile stomatitis independent of mercury is the cause of these changes. 
They must be distinguished from the so-called Hutchinson's teeth. In 
stomatitis which affects the teeth the molars are honeycombed to the 
greatest degree, the incisors affected next. In addition to pitting and 
erosion the color may be darker. A transverse furrow crosses all the 
teeth at the same level. 

The Teeth of Congenital Syphilis. The upper central incisors of 
the permanent set are affected. They are dwarfed, narrowed and 



Fig. 75. 




Notched teeth. Malformation of permanent teeth found in hereditary syphilis. 
(Mr. Jonathan Hutchinson.) 

short. The middle lobe of the tooth is so atrophied as to leave a single 
broad vertical notch in the edge of the tooth. A narrow furrow passes 
upward sometimes from the notch on both anterior and posterior sur- 
faces nearly to the gum. 

It is seen from the above that the appearances of the first set of teeth 
may be an index of the condition of the nutrition of the child in infancy. 
Teething. During the period of infancy it is well to remember the 
influence of the eruption of the teeth upon the general constitution. 
While many prominent authorities believe that the eruption takes place 
without the occurrence of general or reflex symptoms, on the other hand 
equally careful observers believe that nervous phenomena often attend 
the process. The latter class of observers attribute the feverishness, 
restlessness, loss of appetite, and gastro-intestinal disturbance to this 
cause. Convulsions at this period are believed to be due to the pressure 
of the tooth, which cannot break through the mucous membrane, upon 
highly sensitive nerves at the root. Even in later life reflex convul- 
sions are held by some to be due to teeth. 

Slowness in the development of the teeth may be due to rhachitis, 
which should be looked for. The student should be familiar with the 
periods of development, the number of teeth that appear at each period, 
and the date of the eruption. 



436 



SPECIAL DIAGNOSIS. 



Dates op Eruption op the Teeth. 



Milk Teeth. 

2M 1C 41 1C 2M _ 

2M 1C 41 1C 2M — 

Eruption of central incisors about 7th month. 1 

" lateral incisors " 9th month. 

" first molars " 15th month. 

" canines " 18th month. 

" second molars " 24th month. 

Permanent Teeth. 

3M 2B 1C 41 1C 2B 3M _ 

3M 2B 1G 41 1C 2B 3M — 

Eruption of anterior molars about 7th year. 

" central incisors " 8th year. 

" lateral incisors " 9th year. 

" anterior bicuspids " 10th year. 

" posterior bicuspids " 11th year. 

" canines " 11th year. 

" second molars " 12th to 14th year. 

" third molars (wisdom teeth) about 18th to 25th year. 



Stomatitis. 

This inflammation is not limited alone to the mouth, but extends to 
structures within the mouth, as the gums, and may invade the tongue. 
The inflammation is recognized by the subjective and objective signs 
common to such inflammations. There is pain, and hence the child (for 
it usually occurs in children) refuses to nurse or take the bottle, or cries 
when food is given. The pain is accompanied by foetor of the breath. 
This occurs in all forms of stomatitis. Its origin, as well as the origin 
of the pain, is readily determined by inspection. 

On inspection we note the usual signs of inflammation. It is rare 
for the latter to be general ; i is localized to small areas which rapidly 
become ulcerated. When general the mucous membrane is red and 
hot ; the color extends to the sides of the gums and lips and tongue. 
This is seen in the catarrhal form, and in addition the follicles are en- 
larged. The tongue becomes red and smooth, or may be covered with 
a white coating through which the prominent red fungiform papillae 
project. Attendant on inflammation there is increased secretion, which 
dribbles from the mouth, or is constantly discharged by older patients. 
The red hue of the mucous membrane is attended by swelling. The 
heat of the mouth is sufficient often to raise the temperature of the 
expired air so that the breath is hot. 

Aphthous Stomatitis. When the inflammation is more intense 
in local areas ulceration takes place. Thus in aphthous stomatitis small 
yellowish-white spots appear, at first discrete, but soon dotted over the 
mucous membrane inside of the cheeks, in the roof of the mouth, along 
the sides of the gums and on the tongue. They subsequently break 
down into shallow ulcers with raised red margins. 

Ulcerative Stomatitis. The disease occurs in ill-nourished sub- 
jects and is often intercurrent with exhaustive diseases, as chronic 



1 Lower incisors first. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



437 



diarrhoea. It may be seen in epidemic forms in camps, and in penal 
and other institutions on account of unsanitary conditions. In ulcerative 
stomatitis the inflammation is more pronounced on the gums. They 
are swollen, red, and covered with ulcers. The gums which are filled 
with teeth are affected, and the ulcers are usually at the gingival border. 
The ulcers are covered with yellowish material. The flow of saliva is 
much increased in this affection. It is acid in reaction. The sub- 
maxillary glands are enlarged. The fcetor of the breath is very 
great. 

Thrush. In parasitic stomatitis, or thrush, raised white patches are seen 
looking like small curds of milk. The patches vary in size, and upon 
the tongue may cover an area as large as a three- cent piece. The white 
patches are distinguished from milk curds because they cannot be 
removed by the napkin or brush. It has been thought that the parasite 
which is the cause of the inflammation is the o'idium albicans. But 
Forchheimer prefers to group it under saccharomyces. 

Stomatitis Materna. Painful ulcers occur in the mucous mem- 
brane of the lips and cheeks in nursing women. They are solitary 
and interfere with mastication. 

Gangrenous Stomatitis. The affection appears as a gangrenous 
inflammation of the gums, mucous membrane, and deeper tissues of the 
cheek. At first a small, dark red, hard spot is seen, which increases in size, 
and becomes of a purplish color. The cheek rapidly becomes swollen, 
tense and brawny. On the surface of the more indurated portions a 
bleb forms which soon breaks with rapid ulceration. The ulcer is dark 
and gangrenous and soon perforates the cheek. It extends to the jaw, 
followed by necrosis of that bone. The characteristic odor of gangrene 
attends the process. While the affections previously mentioned are 
generally dependent upon poor nutrition, gangrenous stomatitis is always 
secondary to depraved, depressed, or debilitated states of the system. 
Several cases may occur at the same time among children congregated 
in institutions in which there are bad hygienic conditions and to whom 
improper food has been given. 

Mercurial Stomatitis. The gums are involved in ulcerative 
stomatitis, and mercurial stomatitis, or ptyalism, particularly affects these 
structures. It also involves the salivary glands. The inflammation 
is caused by mercury. It may occur from the medical use of the drug, 
particularly in persons who are unduly susceptible, or are not particu- 
lar in regard to mouth-cleansing. The inflammation is painful and 
attended by profuse discharge of saliva, hence the name, salivation. 
The tongue is swollen, marked on the sides by the teeth, and may be 
protruded with difficulty, on account of its size. It is tender to the 
touch. It is covered with a heavy, creamy coating. The gums are 
swollen, red, sore, and bleed on the slightest touch. Ulcers along the 
border occur, may become extensive, and in some instances extend to 
the jaw. The teeth become loosened. The fcetor of the breath is 
heavy, offensive, and of a metallic character. The inflammation is 
usually preceded by a metallic taste in the mouth, and the patient 
notices pain on mastication, which increases in severity as the inflam- 
mation develops. In mild cases it is limited to the gums, in others the 



438 



SPECIAL DIAGNOSIS. 



tongue and salivary glands and the mucous membrane of the mouth 
are affected. 

Ulcers. In addition to the forms just described of ulcerative in- 
flammation of the mouth, ulcers are seen, such as herpes secondary to 
gastric disturbance, and more particularly the ulcers that attend 
syphilis. In the secondary stage of syphilis, mucous patches are seen 
as bright red, symmetrical, oval or crescentic patches or erosions. They 
are generally covered with a scanty grayish-white secretion. They 
are not generally painful. They occur on the mucous membrane, and 
at the same time may be found on the tongue and fauces. 

Sublingual Ulcer. This local ulcer is on the frsenum of the tongue. 
It is seen in whooping-cough, and is due to the rubbing of the tongue 
against the teeth in the act of coughing. 

The Tongue. 

Examination of the tongue is made for diagnostic purposes with a 
greater show of wisdom on the part of the examiner, and greater satis- 
faction to the patient, but with less satisfactory results from a diagnostic 
standpoint, than the examination of any other portion of the body. 
Examination is resorted to because the mucous membrane of the 
tongue is the only mucous membrane of the body, except the oral and 
faucial, which is open to inspection, by which we judge the effects of 
general diseases upon mucous membranes. Because of its relations with 
the gastro-intestinal tract it is thought to be indicative of disorders of 
that tract. Recent studies promulgated by Hutchinson, Butlin, and other 
observers have resulted in views at variance with the above. Both the 
distinguished gentlemen above mentioned are surgeons, and look upon 
the tongue as a local organ. Investigating it as such they concluded that 
the changes in the coating, which had been considered to have so much 
clinical significance, depended largely upon parasitic invasion, and were 
not due to changes in the epithelium. The parasitic invasion, they 
hold, is largely dependent upon local conditions, which, however, it is 
true, are on their part dependent upon a state of the system. Since the 
writings of Hutchinson and Butlin, Dickinson returned to the investi- 
gation on the lines laid down by older teachers, and has, in a measure, 
restored the tongue to its original position as a diagnostic factor in an 
estimation of the state of the general system and in diseases of the 
gastro-intestinal tract. 

We study the tongue with a view to ascertaining its color ; the 
character of eruptions if present ; the occurrence of indentations, 
excoriations, furrows or fissures ; the occurrence of ulcers and of 
patches. Plaques, nodes and nodules are also seen on the tongue. 
Inflammation of the tongue occurs, and it is the seat of atrophy and 
hypertrophy and of various tumors in the parasitic diseases. The move- 
ments of the tongue are also observed, as an indication of the power of 
muscles which are under centric influence closely related to important 
centres in the medulla oblongata. Surgical affections of the tongue 
will not be considered ; local affections will only be referred to in con- 
nection with general diseases. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



439 



Discolorations OF the Tongue. Yellowish-white, oblong patches, 
soft, but slightly raised, are sometimes seen along the sides of the tongue 
— xanthelasma. They are sharply defined and vary in size from a split 
pea to a three-cent piece. Xanthelasma is also situated upon the eyelids 
and upon the palms of the hands, and rarely in other portions of the body. 
It occurs in jaundice or in persons who are said to be subject to bilious 
attacks. 

Addison's Disease. Dark purple or black marks are seen on the 
tongue as well as on the surface of the lips. They are sharply defined, 
neither raised nor depressed, and vary in size. They are dark purple 
in color. Unless associated with discolorations of the skin they are not 
of significance. They are also seen on the tip of the tongue of a bluish- 
black color, while the patches inside of the lips and cheeks are brown. 
Blood-stains are observed in purpura. Bright red spots the size of a 
split pea, or patches, or ecehymoses, are of frequent occurrence. The 
color of ecehymoses is not removed by pressure. Hemorrhagic infarcts 
are sometimes seen on the tip of the tongue. 

Black Tongue. This rare condition is of parasitic origin. It has 
recently been described anew by Cohen. It is also known as nigrities. 
The affected portion is of brownish-black or black color, varying in 
size and usually seated on the middle of the dorsum of the tongue. 
It looks like an iron-stain, and in some instances the surface is rough- 
ened. The papillae are abnormally enlarged. It usually begins as a 
small spot, and extends slowly so that at the end of a month the dorsum 
is covered. The centre is blacker than the circumfereuce. After the 
entire dorsum is covered the spot begins to disappear from the circum- 
ference toward the centre, and is followed by desquamation. This 
series of phenomena is repeated aud the entire affection subsides slowly. 
Desquamation may last from a few days to two months. The papillae 
of the affected surface, too, look like " a field of corn laid by the wind 
and rain." The sensations of taste and touch are not altered, but a 
sensation of dryness is marked. It must be remembered that a black 
tongue is sometimes the result of deliberate deception. 

Inflammation of the Tongue. Acute glossitis is a rare affection, 
more common in adults than in children, and more frequent in men than 
in women. It occurs more frequently in the summer. The onset is 
rapid. After a short period of tenderness on mastication, the move- 
ments of the tongue are stiff or painful, or there are pains in the 
muscles of the neck and submaxillary region. In a few hours the 
tongue swells. It rapidly increases, and at the end of fifteen to twenty 
hours is three times its natural size, protrudes from the mouth, is in- 
dented by the teeth, and is almost immovable, feeling heavy, pain- 
ful and tender. It is coated with a thick fur on the dorsum. Saliva- 
tion accompanies these symptoms, speech is impossible, dysphagia 
extreme and dyspnoea not unusual. The glands underneath the jaw are 
swolleu. The temperature rises to 101°, rarely above it, even if the case 
is severe. Death may occur in a few hours from suffocation, or after a 
longer interval, from diffuse suppuration, exhausting septic fever, or 
pneumonia. Gangrene is more frequent than spontaneous resolution. 
The swelling begins to subside in three or four days. Small ulcers 



440 



SPECIAL DIAGNOSIS. 



form on the surface of the tongue, and by the end of a week its normal 
aspect is regained. The fever and distressing symptoms subside along 
with the local swelling. It is said to be due to colds, to bites and stings 
of animals, to mercury, and to corrosive and acrid substances. It may 
occur in fevers. The diagnosis is easy. It may be difficult to dis- 
tinguish it from acute oedematous swelling due to salivary calculus or 
affections of the floor of the mouth. Acute ranula sometimes causes 
considerable swelling of the tongue, simulating acute glossitis. Hemi- 
glossitis sometimes occurs. The local symptoms are not so great, 
because half of the mouth is occluded only. I saw a case in my early 
connections with the University Dispensary in which the inflammation 
was limited to half the side of the tongue on the posterior surface. It 
went on to suppuration, but was not attended by serious symptoms, 
except discomfort in eating. It was preceded by a definite nodule in 
the substance of the inflamed part. Glossitis from mercurial poisoning 
has been described in connection with stomatitis. 

Chronic Superficial Inflammation of the tongue may also occur. The 
surface is smooth and deprived of papillae over the affected area, which 
is redder than natural. The margin of the raw patch is sharply de- 
fined, but the area has no depth. The epidermis alone is removed. 
When associated with dyspepsia it covers a considerable area of the 
surface of the tongue. It may be deprived of papilla on the front 
part of the dorsum while the fungiform papillae remain. One observer, 
Hack, has described these ulcers as peculiar to certain females. In 
three generations of two females he observed a row of long, oval areas. 
They commenced in early childhood. The tongue was strikingly smooth 
over large areas, with red excoriations here and there. There was no 
syphilis. In chronic superficial glossitis, excoriations are due to slight 
traumatism or to dyspepsia. 

Eruptions. Eruptions of variola, measles and erysipelas are seen 
on the tongue. Herpes and aphthous ulcers, preceded by vesicles, are 
situated on the surface of the tongue. 

Indentations occur when the tongue is swollen, as in mercurial and 
other forms of glossitis. The borders of the tongue are indented by 
the pressure of the teeth. In states of debility a flabby tongue with 
indentation of its borders is often seen. Sometimes the indentations 
are so pronounced that the pressure of the teeth causes ulceration. 

Excoriations on the surface of the tongue, or rawness, arise from 
injury and may be seen in dyspepsia. 

Furrows, or Grooves and Wrinkles, are seen on the dorsal 
aspect of the tougue. They are not necessarily tokens of disease ; in 
many persons they are of constant occurrence. Furrows vary from 
a few lines to an inch or more in length. In mauy this is most striking 
in the middle line of the tongue. The median furrow is liable to be- 
come ulcerated on slight provocation. The edges of the fissures are 
smooth and without papillae or fur. Other furrows are directed longi- 
tudinally and vary in depth. They may be curved and forked. They 
are more frequent in older persons, especially if the tongue is too large 
to lie within the circle of the teeth. They are an evidence of past in- 
flammation, or rarely of hypertrophy. They resemble the median 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 441 



furrow as regards smoothness and absence of fur. Inflammatory fur- 
rows occur in chronic superficial inflammation, but more commonly after 
chronic inflammation which has left the tongue enlarged. The furrows 
are sometimes so abundant that the surface of the tongue looks like the 
eyelid. The raised areas become sore, due to irritation of a foreign 
body (food) or a tooth. They are an indirect result of inflammation. 
True inflammatory furrows, described as dissecting glossitis by Wunder- 
lich, occur. Dissecting glossitis is only a more aggravated form of super- 
ficial glossitis. Furrows of this character may be due to syphilis, and 
dissecting glossitis sometimes has a syphilitic origin. Fissures and clefts 
are usually caused by the rubbing and deep indentation of a rough and 
jagged tooth. The dental fissure may be inflamed around it and be 
seated on an indurated base. The sides and bottom are ulcerated. It 
is recognized by its association with the offending tooth. It may be 
mistaken for syphilis, which is a common cause of fissures. 

Syphilitic Fissures. In secondary syphilis they are always on 
the borders of the tongue ; they are almost certain to occur if the teeth 
irritate the border. They may be due to the ulceration of a mucous 
tubercle which is developed upon the border of the tongue. The ulcer 
is stellate, and gradually deepens until it becomes a foul fissure. Two 
processes cause the ulceration — syphilis and the irritation of the teeth. 
It must be remembered that the tongue is always predisposed to in- 
flame and ulcerate in syphilis. Syphilitic ulcers are not very angry 
like non-syphilitic sores and fissures which are produced in persons 
out of health. They may be sensitive, however, on account of the 
involvement of the tongue. The absence of active inflammation, the 
large number of the sores and fissures, and association with other signs of 
the disease upon the tongue, cheeks, and lips point to their syphilitic 
origin. Tertiary syphilitic ulcers are more pronounced and deeper than 
other forms. They may be as long as two or three inches ; they are 
sinuous and branched. Gummata may occur on the tongue at the same 
time. The gummata may be localized or arranged in lines which break 
down. Sclerosis of the tongue, as described by Fournier, follows the 
healing of these ulcers. It is curious to note that the lymphatic glands 
are seldom enlarged in association with syphilitic fissures. The fissures 
must be distinguished from carcinoma and tuberculosis. In carcinoma 
there is a distinct tumor, which may become fissured. Tuberculous 
ulceration is a sign of association of tubercle in other organs. The 
tuberculous fissures are small, at first single ; tubercle, however, rarely 
begins as fissures, but as tuberculous ulcers on the tip or borders of the 
tongue. They are stellate or irregularly branched. They are shallow 
at first, and deepen later, but do not widen in a corresponding 
manner. The lymphatic glands are always involved (see Tuberculous 
Ulcer). 

Ulcers of the Tongue. They may be simple, aphthous, or 
traumatic. Simple ulcers follow long-standing superficial glossitis. 
They form in the centre of the tongue, or of the diseased inflammatory 
area. They are due to sloughing, or simple melting away of epithelium. 
The ulcer is smooth, red, glazed on the surface. The edges are callous 
and inactive, the shape is irregular. It is sensitive, and may be pain- 



442 



SPECIAL DIAGNOSIS. 



ful. The signs of chronic glossitis continue with it. Dyspeptic or 
catarrhal ulcers occur on the tip or on the dorsum near the tip. The 
dorsum of the tongue from the tip extending back is very red, and fili- 
form papillae are absent. They are small, superficial ulcers without 
definite shape or character, except that they are red and irritable. 
Dyspeptic ulcers may occur from the breaking down of vesicles of the 
tongue. They are small, circular, well-defined ulcers, with sharp-cut 
edges, in size from a pin's head to a split pea, and are the source of 
considerable pain and much annoyance. They are recurrent. Saliva- 
tion may attend them. Aphthous ulcers are seen in children and adults, 
and are attended with the same symptoms as aphthous ulcers of the 
mouth, with slight fever. Foetor is characteristic. Iraumatic ulcers 
from sharp teeth may persist a long time if the general health is bad. 
When active, they may be mistaken for syphilitic sores, and when indo- 
lent for syphilitic, tuberculous, or cancerous ulcers. The rapidity of 
formation, the location opposite a rough tooth, and the absence of other 
signs of syphilis point to its true nature. Chancre must be excluded by 
the greater hardness and circumscription of the lesion, its seat near the 
tip, its association with enlargement of the lymphatic glands. The 
latter is not present in traumatic ulcer, unless it is acute and angry. It 
is distinguished from tuberculous ulcers by the absence of signs of 
tubercle in other organs and by the result of an examination of the 
scrapings of the ulcer ; from cancer by the age. In cancer, all the 
glands become affected later. 

Tuberculous Ulcer. The tuberculous ulcer presents an uneven, 
pale, flabby surface, covered with a yellowish-gray viscid or coagulated 
mucus. The edges are sometimes sharp-cut, sometimes bevelled, seldom 
elevated. They are not usually very red. There is but little surround- 
ing inflammation, and the adjacent portions of the tongue are but 
slightly swollen. The borders of the ulcer may be sinuous, and the 
shape oval or ovoid, or elongated. In the neighborhood of an ulcer a 
number of tiny yellowish-gray points may be observed. The ulcer is 
painful, and attended by salivation. I saw in the Philadelphia Hospital 
a case of tuberculous ulcer of the tongue, in a young man twenty-five 
years of age, with pulmonary and intestinal tuberculosis. The dorsum 
of the tongue was covered with a dozen ulcers with sharp-cut edges 
and pale, flabby granulations, without induration or inflammation around 
them. They were yellowish gray, and in scrapings of them, tubercle 
bacilli were found. Tubercular ulcer must always be diagnosticated 
from syphilitic and cancerous ulceration. The associate symptoms are 
often most reliable. Ulcers due to lupus are also seen upon the 
tongue. 

Patches and Plaques. Space forbids further consideration than 
the naming of the plaques which are seen on the tongue. First, there 
is the smoker's patch on the middle part of the dorsum about the point 
where the tobacco-pipe rests, or where the stream of smoke from the 
pipe or cigar strikes the tongue. This is a slightly raised area of oval 
shape. It is not ulcerated, but is smooth and red, or livid. Sometimes 
it is bluish-white or pearly in appearance. The smoothness is character- 
istic. White and bluish-white patches or plaques are seen in leucoma, 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



443 



leucoplakia, ichthyosis, keratosis, and are also known as opaline plaques. 
The smoker's patch belongs to the same class, and is probably an early 
stage of the affections. It means a whiteness, or white opacity of the 
surface of the tongue, usually on the dorsum. It is almost always the 
result of the direct action of irritants. These patches are unknown 
uuder twenty years of age, do not commence after sixty, and very 
rarely attack women. They are not attended by subjective symptoms 
usually. There may be a sensation of induration and dryness. The 
course is always chronic. 

Chronic Superficial Glossitis. The whole dorsal aspect of the 
tougue is smoother than natural, the mucous membrane is redder than 
normal, the surface uneven. The papillae have disappeared. Excoria- 
tions and superficial ulcers usually accompany the inflammation. The 
tongue is enlarged and its borders marked by the teeth. The surface 
looks glossy. The tongue feels stiff and uncomfortable. Movement is 
irksome, irritating foods are hurtful. Spirits and tobacco cause distress. 
Indiscretions in diet quickly produce fresh inflammations. 

Wandering Rash. Ringworm, or circular exfoliations occur most 
frequently in children. One or more patches on the surface of the 
dorsum of the tongue are observed, smooth and red, but not depressed 
or elevated. The filiform papilla? have been shed. The patch 
spreads and becomes a ring, circular or oval. The border is faintly or 
decidedly yellow, and usually slightly raised and sharply defined. The 
circles may widen and contract from time to time. No subjective symp- 
toms are noted except itching in a few cases. The cause is not known. 
The diagnosis is easy. It may continue for months or years. 

Mucous Patches are multiple lesions of syphilis in the mucous 
membrane. They have been referred to in the section on Diseases of 
the Mouth, and further reference to them will be found in works on 
surgery. 

Nodes or nodules in the tongue are always tuberculous or syphilitic. 

Atrophy of the tongue is very unusual ; hemiatrophy may occur as 
the effect of central or peripheral causes, as softening, hemorrhage, or 
tumors of the region of the hyperglossal nucleus. Other centres near 
the nucleus are affected, hence other forms of paralysis are seen, due to 
the lesions of the medulla. These are seen iu progressive muscular 
atrophy and bulbar paralysis, and in cases of hemiplegia. It is not 
difficult to recognize it on inspection. The functions of the tougue are 
not affected. Hypertrophy of the tongue, or macroglossia is gen- 
erally congenital, but may occur late in life. The tongue enlarges, and 
is accompanied by pressure symptoms, due to such enlargement. Hyper- 
trophy of the tongue is sometimes seen in idiots and cretins. The 
hypertrophy is more frequently the result of lymphatic obstruction, 
on account of which there is lymph-stasis. The diagnosis is easy. 
Inflammatory hypertrophy occurs in stomatitis, and syphilitic hyper- 
trophy occurs with gummata. Cysts. Various cysts occur in the 
tongue. The mucous cysts and blood cysts are the most common. The 
mucous cyst, the cysticercus cellulosse, and the echinococcus occur 
rarely. Ranula is a cyst underneath the surface of the tongue that 
causes mechanical suffering. It is easy of recognition. 



444 



SPECIAL DIAGNOSIS. 



Parasitic Disease of the Tongue. — Thrush is the most com- 
mon. 

The Effects of General or Remote Disease on the Tongue. 
The Coating. With a view to estimating the condition of the system in 
general from the appearances of the tongue, excluding all local condi- 
tions, the following characteristics are observed : first, the color ; second, 
the fur ; third, the degree of moisture ; and fourth, the movements. 
The student should bear in mind that changes in the condition of the 
tongue are frequently of local origin ; that dryness, for instance, may 
be due to the open mouth, or that a coating may be unusually marked 
because the tongue had not been used in mastication. Often coating is 
seen on one side of the tongue. This has been referred to as due to dis- 
ease of the nerve of one side. It is just as likely due to an absence 
of mastication on that side of the mouth, the bolus of food being 
kept on the other side because of pain, diseased teeth, or other local 
cause. 

Clinical experience has shown that certain states in the tongue are 
associated with certain general conditions which render the appearance 
somewhat diagnostic. The term diagnostic must be qualified because of 
the fact that the changes are so often local, or that they are modified by 
conditions independent of the general system. For convenience, the 
classification of Dickinson as to the appearance of the tongue in disease 
may be utilized. In the Lumleian lectures this eminent authority de- 
scribed the average healthy tongue based on extensive observations. 
Departures from the normal were arranged and afterward classified. It 
resulted in the formation of eleven classes. The first was the stippled 
or dotted tongue. The tongue was moist and dotted with little white 
points, due to an excess of white epithelium on the papillae. It is 
usually seen in persons in poor health without fever. It is not, there- 
fore, a febrile tongue, nor one indicative of grave constitutional disease. 
It is seen iu cases of chronic disease, usually in which there were no 
grave symptoms. Second, when dryness attends the stippled tongue 
it is fouud in mild acute diseases, or in cases in which the constitu- 
tional disturbance is more marked. The third class is stippled and 
coated. The patients in whom this is found very frequently are the 
subjects of acute and constitutional affections. Fever is more fre- 
quently present in cases of this fur. Fourth, the coated tongue. There 
is excess of white epithelium on the papillae, and the coat is continu- 
ous. The intervals between the papillae are filled up with epithelium 
and accidental matters more commonly than in the preceding. It is seen 
in the acute and febrile diseases. In the moist and dry kinds, pneu- 
monia, pleurisy, typhoid fever, and other febrile disorders make up 
the list. Prostration and pyrexia attend the cases in a far greater 
degree than the preceding, while the saliva is absent in a larger pro- 
portion of the cases. 

The Strawberry Tongue. The tongue is coated and injected, the fungi- 
form papillae shine through the coat, particularly at the tip and edges. 
It is the tongue of scarlet fever, but may be seen in any acute febrile 
disorder. Pyrexia is more common in this class than in the pre- 
ceding. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 445 

The Plaster Tongue. A thick, uniform coat, abrupt and striking, 
covers the tongue. The papillae are elongated and the intervals crowded 
with accumulations, among which are bacteria; it is the tougue of acute 
febrile disease. Fever was marked in a number of cases Dickinson 
studied, and prostration was a common attendant. Saliva was deficient. 
It is thus seen that, beginning with the healthy tongue, Dickinson 
described a series of groups, in each succeeding one the coating becoming 
more marked, with or without moisture. The clinical association that 
he found is a common experience. Each successive group was attended 
by more fever and greater exhaustion and less saliva than the preceding 
group, and in each the tongue became more and more furred. 

The Furred or Shaggy Tongue. When moist, the papillae are greatly 
elongated, composed mostly of horny epithelium. It has the same appear- 
ance as if the tongue was dry. The moist, furred tongue is not as common 
as the other. It is most commonly seen in old age and in constipation. 
The dry, furred, or shaggy tongue may succeed the dotted tongue or 
the coated tongue in the course of advancing disease. It is the result of 
disease and want of moisture. The saliva is deficient; there has been 
fever and possibly but little food used. 

The Incrusted, Dry Brown Tongue. Over the surface of the tongue 
there is a dry, thick, felted coat, which is continuous and dips down be- 
tween the papillae. The coat is largely made up of parasitic material. 
In the course of fevers it is the outcome of a preceding condition, the 
coated tongue, and is indicative of the typhoid state. It occurs in 
the fevers with high temperature, but may be seen in conditions of 
low temperature, as from cancer, phthisis, albuminuria, chronic nervous 
diseases. There is much depression or prostration associated with it, 
and there is absence of saliva. If the patients with a dry brown 
tongue recover, it retrogresses to the furred or incrusted tongue, which 
in turn becomes bare gradually, at first in small layers ; it is thin, 
usually dry, but is more moist than the dry brown tongue As the in- 
crustation disappears it may become bare, red, and dry. The red dry 
tongue indicates a more serious condition usually than the dry and brown. 
It is the tongue of chronic wasting diseases. It occurs in phthisis in 
the later stages, and, as the raw-beef tongue, is associated with dysentery 
and also with liver abscess. There may be fever associated with the 
cases. It is in a measure the tongue of chronic diarrhoea, and particularly 
the form known as tropical diarrhoea. The tongue is shrunken, red, 
polished, and smooth. The papilla? have disappeared and the epithelium 
stripped off in patches. It may be associated with aphthae. If the 
patient is to improve, the redness fades, the papillae become softer, and 
the moisture returns. 

Cyanosis, or Venous Congestion of the Tongue. The tongue is of a 
bluish or purplish color, the surface is smooth and wet, and the papillae are 
almost indistinguishable. It is not confined to organic heart disease or 
cyanosis. It is of quite frequent occurrence in albuminuria. With the 
venous congestion in the albuminuric cases there is always a superabund- 
ance of deep epithelium. When the surface is examined it looks as 
though the papillae were fused together, over which may be laid a mod- 
erate coat. 



446 SPECIAL DIAGNOSIS. 

Classification of Tongues. 


To the naked eye. 
1. Healthy, moist. 


Microscopically. 

White epithelium in small amount on papillae, not con- 
tinuous or superabundant. 


2. Stippled, moist, dotted with white. 
2 (D) 1 . Stippled, dry. 


Excess of white epithelium on papillae, not extending 
between them. 

Ditto. 


3. Stippled + coated ; moist. Coat con- 
tinuous in parts. 


White epithelium on papillae in excess with partial filling 
of intervals. 


4. Coated white ; moist. Coat continu- 
ous. 

4 (D). Coated white, dry. Coat con- 
tinuous. 


Excess of white epithelium in papillae. Intervals more or 
less filled up with epithelium and accidental matters. 

Ditto. 


5. Strawberry, coated + injected, espe- 
cially showing in fungiform papillae 


Like the coated or plastered, but with more injection. 


C. White, plastered, thick, uniform 
coat, abrupt and striking. 


More elongation of papillae than with coated tongue, more 
filling of intervals with superficial accumulation. 


7. Furred or shaggy, moist. Greatly 
elongated papillae. 

7 (D). Furred or shaggy, dry. 


Extravagantly long papillae, mostly of horny epithelium. 
Ditto. 


8. Incrusted, dry, brown; thick, felted 
dry coat over papillae. 


Continuous crust on and between papillae, largely of 
parasitic matters. 


9. Furred or incrusted, becoming bare. 
Generally dry. 


Crust breaking away, together with more or less of normal 
surface. 


10. Denuded, red. Absence of normal 
covering. 


General absence of all epithelium excepting the Mal- 
pighian layer ; sometimes of that also. 


11. Red, smooth, dry, membranous 
covering. 


Level membrane replacing epithelial processes. 


12. Cyanosed. 


Injected ; hypernucleated ; excess of deep epithelium. 



Moisture of the Tongue. The moisture is due to the saliva 
generally, any deficiency of which causes dryness of the tongue. It is 
natural, therefore, to appreciate that any changes in the moisture of the 
tongue are due to the secretion of the salivary glands. Fever is almost 
always present when this is deficient, and hence the tongue is dry. At 
the same time this failure of secretion of the salivary glands does not 
attend diminished secretions elsewhere, unless it should be the glands of 
the gastro-intestinal tract. 

Dryness of the tongue, it must not be forgotten, may be due to 
increase of evaporation due to exposure of the mouth by persistent 



1 The letter D is used to imply dryness. Thus, to Class 2 a certain description is attached. Class 
2 D presents the same characteristics with the addition of dryness. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



447 



openness, in addition to diminution of the salivary secretion. All states, 
therefore, in which the mouth is open will lead to dryness of the tongue. 
Again, in chronic fever, dryness of the tongue is a constant character- 
istic. Dryness is due to the effects of the temperature upon the secre- 
tions in general, but it is not the effect of high temperature, curiously, 
but rather a temperature which has persisted for a considerable length 
of time. Thus, in pneumonia, with a temperature of 105,° the tongue 
may be moist; whereas, in typhoid fever, with a temperature of 103,° 
the tongue is dry. General dehydration of the body causes dryness of 
the tongue, even without diminution. This dehydration is seen in 
diarrhoea, in which disease simple or uncomplicated dryness of the 
tongue is a common symptom. It is curious to observe that in cholera 
the tongue remains moist even until death ; whereas, if the patient is 
about to improve and the discharges cease, reaction and fever setting in, 
the tongue begins to dry and becomes quite brown. Local causes may 
explain this. The watery vomit may keep the tongue moist, and the 
temperature of the body may contribute to the change. Next after 
diarrhoea we find excessive discharge of urine the cause of dryness. 
Hence, in diabetes in all forms, extreme dryness of the tongue is seen. 
The osmotic action of the sugar in the blood is the cause of a reaction 
in diabetes mellitus, just as it is in cases of dehydration of the lens in 
cataract. The final cause of dryness of the tongue is prostration. As- 
thenia in all forms which continues over a moderate period of time, as 
a week or ten days, causes lingual dryness. 

The Effects of Food. These must be studied before deciding upon the 
clinical significance of changes in the tongue. The immediate results 
of food have influence in determining the coating and the degree of 
moisture. The act of eating cleans the tongue. In disease, therefore, 
in which this act is not performed, it is natural that we observe 
more fur on the surface, and in conditions in which diet is limited to 
fluids the effect is marked. In cases of liquid diet, the tongue is liable 
to remain furred. It is particularly seen in patients who are kept upon 
a milk diet exclusively. 

The Tongue in Eelation to Diseases of the Alimentary 
Canal. So much has been written on this sbbject that it is well to 
give the experience of Dickinson briefly. He declares that he has not 
been able to discern any relationship between any state of the tongue 
and dyspepsia and ulcer of the stomach apart from that which might 
occur from loss of appetite or limitation of the food. With regard to 
the bowels, some forms of constipation are often connected with changes 
in the tongue, but such connection is not necessary. The author rather 
thinks it to have been a coincidence, and cannot even point to the diag- 
nostic significance of the tongue in obstruction. The state of the tongue 
in the latter condition is dependent, not upon the intestinal lesion, but 
upon the constitutional disturbance. A dry tongue is well known to 
occur in acute obstruction. He thinks that this is due to deficiency of 
salivary secretion ; unless, however, there is constitutional disturbance, 
he does not think that in chronic obstruction the tongue will change. 
In diarrhoea all conditions of dryness, furring, and incrustation are 
osberved. The absence of saliva, dehydration, and pyrexia help the 



448 



SPECIAL DIAGNOSIS. 



desiccation. In diarrhoea and dysentery, therefore, the change in the 
appearance of the tongue is more marked than in any other disease. 

Other Diseases. In relation to other individual diseases but little 
may be said. Of more direct association, we have the tongue of 
heart disease, of which the cyanotic character is evident, a similar con- 
dition sometimes accompanying chronic albuminuria and diabetes mel- 
litus, in which there is excessive dryness ; the tongue of scarlet fever 
and of typhoid fever have been referred to, the strawberry tongue of 
the former being almost pathognomonic. Of course the so-called 
typhoid tongue represents but one stage of typhoid fever. Throughout 
the disease it may present all varieties in direct succession, from the 
stippled, the coated, the plastered, the furred, to the incrusted. In 
lobar pneumonia the same changes occur as the disease advances. In 
bronchitis the lower degrees of coating are presented, while in rheuma- 
tism the variety is considerable. In conclusion, it may be stated that 
the tongue seldom points to solitary organs or isolated disorders, but is a 
gauge of the effects of disease upon the system. 

The Tongue in Treatment and Prognosis. Clinical observers 
agree with Dickinson that the condition of the tongue is due very largely 
to the four states with which he has associated it — dehydration, exhaus- 
tion, pyrexia, and local conditions about the mouth. As these conditions 
cause the state of the tongue, it is evident that the first sign of its improve- 
ment, as return of moisture, denotes a diminution in temperature. Its 
appearance is, therefore, of good prognostic omen. The condition of fever, 
the state of the nervous system, the maintenance or abeyance of secre- 
tions, and failure of vitality, are indicated by the condition of the tongue. 
The return of moisture, the removal of fur, the subsidence of tremor, 
at once indicate that the patient is getting better. The persistence and 
increase of these signs show that the disease is getting the better of the 
patient. As to indications for treatment, the dryness, furring, and in- 
crustation are connected with the want of saliva. The processes by which 
this want is brought about differ. They have previously been referred 
to, and the indications for treatment are obvious. The inference from the 
state of the saliva as to the condition of the intestinal canal is of the 
highest importance practically. There is no doubt that, except in diabetes, 
when there is diminished saliva, there is also diminished gastrointes- 
tinal secretion. Such diminution is followed by loss of appetite and 
impairment of digestion. The indication is to at once administer material 
that is digested with the least difficulty. Hence liquid food and stimu- 
lants are to be used. The dry and bare tongue is of serious prognostic 
omen in all conditions. While it may be due to want of saliva alone, 
it also occurs as a part of the failure of nutrition in hectic fever, suppu- 
ration, and other conditions. It is an indication for the use of tonics, 
stimulants, and food, probably liquid, always nourishing. The weak 
pulse does not more surely tell of asthenic tendencies than the red, dry, 
and polished tongue. 

Movements of the Tongue. When the patient is asked to put 
out his tongue in health he complies without any undue movement save 
that required for its ejection. In general states, or in disease which has 
caused an interference with its motility, the projection is attended by 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 449 



abnormal movement. It may be tremulous, as in alcoholism or weak- 
ness. It may be slow or impeded iu the stages of various paralyses. It 
is tremulous and the seat of fibrillar contractions in general paralysis. 
In glosso-labial paralysis the tongue cannot be projected at all. In gen- 
eral paralysis and diphtheritic paralysis, progressive muscular atrophy 
and hemiplegia, the paralysis is only partial, and heuce, while projected, 
it is done with difficulty, and may have to be aided by the finger. In 
hemiplegia, iu which the face is involved, the tongue points to the para- 
lyzed side of the body. 

Angina Ludovici. Angina Ludovici is characterized by slight 
inflammatory congestion of the throat out of proportion to the symp- 
toms of the inflammation in the external structures. Woodeny indura- 
tion, which will not receive impressions, of the connective tissue, 
spreading of this induration instead of fading off, so that it is bouud 
sharply by unaffected cellular tissue, may extend from the rami of the 
jaws to the face. With this there is a hard swelling in the tongue and 
along the interior lower jaw, causing thickening of the floor of the 
mouth. This is observed by palpation with the finger iu the mouth. 
The glands are not affected. For a long time the nature of this affec- 
tion was not known. It is now believed to be due to actiuomyces. 
(See Parker, Lancet, 1879, and Anderson, Transactions of Medico- 
Chirurgical Society, 1891.) 

The Fauces and Pharynx. 

The passage-way between the mouth and the respiratory passages is 
lined with mucous membrane, which is subject to diseases to which they 
are liable. The symptoms thereof are similar to the symptoms of 
mucous membrane inflammation elsewhere. The large muscles of the 
pharynx which aid in deglutition are subject to affections which belong 
to muscular tissue generally, hence rheumatic inflammation and loss of 
power of the muscle, or paralysis, occurs. Situated in the position that the 
pharynx is, it is particularly liable to infection from micro-organisms. 
The infection may extend from the mouth, or above from the nares, or 
the micro-organisms may affect this locality primarily. As a passage- 
way or channel, the affections of the pharynx are liable to occlude it, on 
account of which symptoms arise due to the occlusion. In addition to 
its function as a simple channel, the pharynx is concerned in the act of 
deglutition. When, therefore, there is obstruction of the pharynx, 
deglutition is made difficult, or even may become impossible. As a 
channel for the passage of air, obstruction in the pharynx will lead to 
dyspnoea. 

The fauces and pharynx may be the seat of morbid processes which 
occur secondarily to diseases in other portions of the body with a 
moderate degree of frequency. It is true that inflammations of the 
mucous membrane of the pharynx have to bear the blame of rheu- 
matic or gouty origin in a large number of cases, according to the 
opinion of many observers. Indeed, gouty inflammation of the pharynx 
seems to be more common than gouty inflammations of mucous mem- 

29 



450 



SPECIAL DIAGNOSIS. 



branes in other situations. In the large majority of pharyngeal inflam- 
mations that are subacute or chronic they are secondary to dyspepsia. 
The secondary processes occur chiefly from extension of the disease in 
the cavities related to the pharynx, and are not of special diagnostic sig- 
nificance. The following pharyngeal diseases point to primary conditions, 
general or localized, elsewhere. 

Paralysis of the pharynx does not have the diagnostic significance of 
central lesions that paralysis of other structures, as parts of the larynx, 
have. This is due to the fact that the nerve supply of the pharynx is 
derived from a nerve (glosso-pharyngeal) which supplies other structures, 
paralysis of which is more readily ascertained, and which causes more 
pronounced symptoms. (See Cerebral Nerves.) Affections of the tonsils 
are usually more common in rheumatic states, and bear some relation- 
ship to the rheumatic diathesis. Inflammation of the tonsils may follow 
acute rheumatism or may alternate with it. A patient who is predis- 
posed to rheumatism may at one season have tonsillar inflammation, at 
another rheumatism. The writer has seen tonsillitis immediately fol- 
lowed by rheumatism. 

Apart from what has just been said, diseases of the pharynx bear but 
little if any diagnostic relationship to disease elsewhere. While there 
may be cyanosis of the mucous membrane^ or tuberculous ulceration, or 
other changes which we have noted, the signs of the primary disease are 
so much more marked coincidently in other situations that we need not 
rely upon the appearances of the pharynx or symptoms of pharyngeal 
disease for diagnostic purposes. The only general affection which may 
be diagnosticated from the appearance of the pharynx alone, is measles. 
In obscure cases of sudden fever, with nasal catarrh, the appearance of the 
eruption in the situation previously indicated may lead to the recogni- 
tion of measles when the external eruption is not characteristic. For 
the purposes of the therapeutist it should be borne in mind that symp- 
toms referable to the pharynx are very frequently due to disease in the 
nares, and particularly in that portion of the pharynx which is not open 
to direct inspection — the naso-pharynx. 

The general symptoms of pharyngeal disease are not marked, except 
in diphtheria, in erysipelas, in retro-pharyngeal abscess, and in affections 
of the tonsils. In the latter the general symptoms appear to be out of 
proportion to the local process. The high fever, the intense headache 
and backache, and rapid pulse, point to a process which in extent and 
severity should far surpass that which occurs in the tonsils. 

Attention cannot be too strongly directed to the investigation of the 
naso-pharynx in children who are poorly developed physically, in whom 
there is backward mental development, and who present appearances 
that, to the practised eye, are most familiar. The experienced observer 
will at once judge, and judge correctly, that this combination of symp- 
toms is due to disease in the naso-pharynx. Reference must be made 
to the remarks on adenoid vegetations of the naso-pharynx, but it is 
proper to state here the relationship and the importance of investigating 
the structures in the class of cases just indicated. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 451 



The Objective Symptoms. 

The objective symptoms are noted by inspection of the pharynx. 

The Examination of the Fauces. For this purpose examina- 
tion is made by the unaided eye, but with the part illuminated in the usual 
manner. The difficulties arise from the tongue and the uvula. The 
mouth should be opened in a relaxed manner, not so wide as to be a 
strain upon the patient, but as wide as is consistent with comfort. The 
tongue is pressed down out of the way by the use of a tongue depressor. 
In many cases, however, even with the tongue depressor, the tongue mus- 
cles will contract and the organ bunch up in the mouth. Moderate, 
quiet, full breathing, gently opening the mouth as the deeper inspira- 
tions are made, causes the tongue to be relaxed and lie in the bottom 
of the mouth, and at the same time elevates the uvula. At the time of 
the full breath the part may be inspected throughout. Sometimes the 
fauces can be examined if the tongue is protruded and held between the 
finger and thumb of the patient with a soft napkin. In the fauces the 
tonsils and uvula are to be observed, following out the routine method of 
ascertaining all facts. Attention is then paid to the posterior wall of 
the pharynx with the same object in view. 

Method. On examination of the fauces and pharynx, observation is 
made of the color of the parts, the appearance of the mucous membrane 
and its glands, the appearance and position of the uvula, the size of the 
tonsils, the character of the secretions on the pharynx, and the presence 
or absence of swellings and abnormal exudations. 

Color. The color of the mucous membranes generally is of a dark red 
hue. The color is increased in intensity in acute inflammations of the 
pharynx, whether primary or secondary. In the acute forms it is 
bright red in color. In cases of heart disease, when there is cyanosis, 
the veins are congested. In obstruction of the superior vena cava by 
tumor there is similar change in hue of the surface of the pharynx. 
The capillary vessels may pulsate in aortic regurgitation. Bleeding- 
points may be seen over the surface of the pharynx, w r hich may give 
rise to hemorrhage to such a degree as to simulate pulmonary hemor- 
rhage. The blood may be swallowed and then vomited and the patient 
be thought to have a gastric hemorrhage. When the hemorrhage occurs 
at night it is seen on the pillow as yellowish stains. It is often due to 
adenoid vegetations in the naso-pharynx. 

On examination of the posterior wall of the healthy pharynx little 
elevations due to glands are seen upon its surface, and moderately sized 
vessels are seen coursing through the mucous membrane. 

Eruptions. Eruptions may be observed in the pharynx in some of 
the specific fevers. Thus, in measles, the appearance of the rash on the 
pharynx and the soft palate may be observed before the development of 
the rash on the surface of the skin. The eruption of scarlatina is also 
seen in the pharynx, and the papules and pustules of variola are fre- 
quently observed in that affection. 

The Tonsils. The tonsils are situated at the sides of the pharynx 
between the anterior and posterior folds of the palate. They are 
pathologically of much importance. They are made up of glandular 



452 



SPECIAL DIAGNOSIS. 



structure arranged in follicles and held together by connective tissue. 
The crypts of the follicles open on the surface, and in disease are 
visible. The tonsils are small bodies, not larger than a filbert in the 
adult. Their entire surface cau usually be seen by ordinary inspection. If 
enlarged the posterior surface cannot be seen, although a larger view 
may be obtained by causing the patient to gag or retch, during which 
they are brought forward to the light. The diseases of the tonsils do 
not have any relationship to their function as far as known. The tissue 
and gland follicles are liable to inflammations, which may be bacterial 
or may be the result of rheumatism. The tonsils become enlarged; 
the swelling takes place rapidly in the acute forms. They may be 
simply enlarged and the covering membrane intensely red. In other 
forms of inflammation the surface may be dotted over with white 
points, due to exudation from the follicles, which may be covered with 
a white or grayish membrane, which is removed with difficulty, leaving 
an abraded face underneath. Repeated attacks of inflammation cause 
chronic enlargement of the tonsils. They are enlarged sometimes to a 
great degree, filling almost entirely the lumen of the fauces. The sur- 
face is irregular, and may be scarred. The mouths of the follicles may 
be dilated. By virtue of their position, enlarged tonsils from any cause 
are the source of dyspnoea and dysphagia. The tonsils may be the seat 
of sarcoma. 

The Uvula. In health it hangs midway from the palate. It 
varies in shape from congenital causes, and may be elongated on account 
of disease. This particularly takes place if there has been hawking or 
coughing on account of chronic nasal catarrh. When elongated it is 
pointed and may extend almost to the base of the tongue. The uvula 
may be swollen and oedematous. The oedema is usually associated with 
subcutaneous oedema in the course of Bright's disease. It may occur 
in debility. In both conditions it may become so enlarged as to inter- 
fere with swallowing and breathing. In some cases of pharyngitis the 
uvula is the seat of intense inflammation and great oedema. In addi- 
tion to the constant cough which it causes there may be dyspnoea and 
repeated attacks of strangulation. 

Hemorrhagic infarcts may take place in the uvula. In two instances 
under the writer's care the intense infarction led to sloughing, and in 
one the uvula was swallowed. 

Ulceration. Follicular Ulceration. Small superficial ulcers corre- 
sponding to the follicles may be seen over the posterior wall of the 
pharynx. They occur in chronic catarrh, and are due to the inflamma- 
tion of the follicles. In addition, ulcers secondary to infectious pro- 
cesses are sometimes seen, as in typhoid fever. In syphilis, in the secon- 
dary stage, small, shallow ulcers are seen, on the posterior wall of the 
pharynx. They do not cause pain. Mucous patches are observed at 
the same time, not only on the pharynx, but also in the mouth. In 
the tertiary stage, deep ulcers, followed by scars, are seen on the pos- 
terior wall of the pharynx. Although the absence of pain renders it 
probable that they are of syphilitic origin, nevertheless the history of 
infection aud of the primary lesion, and the evidence of the disease in 
other structures may be secured before diagnosis is fully established. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 453 



In the tertiary forms it may be necessary to resort to the therapeutic 
test. 

Tuberculous ulcers are irregular and the floor grayish. They are seen 
in tuberculosis in its later stages. They are the source of extreme 
pain. There is usually ulceration in the larynx at the same time, and, in 
extremely rare cases, tuberculous ulceration of the tonsils. In a patient, 
a lad of sixteen, under the writer's care, the large tonsils were of a 
honeycombed appearance on account of the grayish, irregular ulcera- 
tion. Deglutition was absolutely impossible on account of the pain, 
and the young man died of starvation. In tuberculous ulceration, after 
the application of cocaine, a portion may be scraped off, and a microscopi- 
cal examination will show the presence of bacilli. 

Cancer of the pharynx is rare, and is usually secondary. The dis- 
ease has advanced from other situations. 

Exudations on the tonsils are due to inflammation of the follicles, to 
diphtheria, to the pseudo-diphtheritic inflammation which attends scar- 
latina, or which arises secondarily to other infectious debilitating dis- 
eases, and to thrush. On the pharynx the exudation may be due to 
diphtheria, to pseudo-diphtheria, or to thrush. The method of distin- 
guishing the various forms will be considered in the articles on the re- 
spective affections just mentioned. In diphtheria the membrane is made 
up of fibrin arranged in a network, in the meshes of which epithelium, 
blood and pus corpuscles and micro-organisms are found. When 
removed, hemorrhagic abrasions and raw purulent inflammation re- 
main. The two forms of bacilli are found in the membrane; the 
pseudo-diphtheritic bacillus or streptococcus, and the true, or Loffler's 
bacillus (see Bacteriology). The Loffler bacillus is best detected by 
cultivations. After the membrane is removed with the usual antiseptic 
precautions and washed in a 2 per cent, solution of boric acid, it is 
cultivated in blood-serum. 

The pseudo-diphtheritic bacillus likewise grows, but its appearances 
are different. 

Anaesthesia. In addition to the evidences of pharyngeal disease, 
observed on inspection by means of the probe, alterations in the sensibility 
of the pharynx may be detected. In the whole posterior wall of the 
pharynx sensation may be absent. This may occur in hysteria, in 
bulbar paralysis, and in diphtheritic paralysis. On the other hand, 
there may be an apparent hyper cesthesia. In some individuals the 
pharynx is particularly sensitive to the presence of foreign bodies, as 
inflammatory exudates, and may resent their presence by sudden cough- 
ing and retching. Inflammations increase the hyperesthesia of the 
pharynx, and it is sometimes observed in hysteria. 

The cervical glands. The pharynx is in such intimate connection 
with the large lymphatic glands in the neck that diseases of the former 
are frequently attended by enlargement of the latter. The glands that 
are enlarged are situated at the angle of the jaw. The lymphatics ex- 
tending down the neck along the vessels may also be enlarged. In 
cases, therefore, of enlargement of the glands in this situation it is 
absolutely essential to examine the fauces and pharynx. 

Leptothrix of the Tonsils. In healthy persons the plugs which block 



454 



SPECIAL DIAGNOSIS. 



the tonsillar crypts are found to be made up of cells and segmented 
fungi. The latter stain bluish-red with the iodo-potassic iodide solu- 
tion. Sometimes the micro-organisms extend beyond the follicles, 
covering the surface of the tonsils with patches of various size. They 
are thus seen in follicular tonsillitis. 

Subjective Symptoms. 

Pain. In affections of the fauces and pharynx pain is one of the 
most common subjective symptoms. It is due to the fact that the 
functional acts of the pharynx require movement of all the structures. 
When they are the seat of inflammation, or ulceration, the movement 
excites pain. It is, therefore, an intense symptom of inflammation of 
the tonsils and pharynx, of rheumatism of the muscular structure of the 
pharynx, and of tuberculosis and cancerous ulceration. Pain in the 
pharynx is a frequent accompaniment of post-nasal inflammations, the 
pharynx not being the obvious seat of inflammation. 

Dryness. Dryness of the fauces, with tickling sensation and a more 
or less constant desire to hawk, occurs in pharyngitis. Hawking, 
however, is not a symptom of disease of the pharynx alone. Its occur- 
rence can only be explained, often, by disease in the posterior nares. 

The Odor of the Breath. In follicular tonsillitis a peculiar 
odor is given to the breath. This is more marked in the milder grades 
of inflammation, with retention of the secretion of the glands. The 
odor is intense and foetid. In cancer and syphilis there is also foetor of 
the breath. The presence of the foetor may be of diagnostic significance 
in the distinction of cancer from tuberculosis. 

Dysphagia. The symptom varies in degree from slight difficulty 
in swallowing to complete prevention of the act. Any disease which 
occludes the passageway causes dysphagia, but it occurs independent of 
obstruction, on account of pain. It is, therefore, present in all painful 
affections. The pain causes the difficulty of deglutition. Dyspnoea is 
seen in tumors, in inflammation of the tonsils, in the rare form of ery- 
sipelas of the pharynx, and in retro-pharyngeal abscess. It occurs from 
occlusion of the passages, and is more marked in retro-pharyngeal 
abscess and erysipelas than in other conditions. In certain forms of 
abscess of the tonsils it may be very extreme. 

Spasm of the pharynx is a subjective symptom that the patient com- 
plains of in some cases of intense pharyngitis. The degree of spasm or 
the amount of choking sensation is largely dependent upon the neurotic 
constitution of the individual. It may be extreme when only a 
moderate amount of inflammation is present. It is seen in the most 
aggravated form in cases of hydrophobia. 

Tonsillitis. 

Acute inflammation of the tonsils may be confined to the follicles, to 
which the term follicular tonsillitis is applied, or it may be limited to 
the mucous membrane, when it is known as catarrhal or erythematous 
tonsillitis. If with the catarrhal inflammations vesicles appear on the 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 455 

mucous membraue of the surface, the term herpetic tonsils is applied to 
it. When the inflammation extends to the stroma of the glands it goes 
on to suppuration. It is characteristic of all forms of acute inflamma- 
tion of this gland to recur frequently in the same subject. The relation- 
ship to rheumatism has been spoken of. This relationship applies in 
both the acute and the suppurative forms. All varieties may occur at 
any age, although it is least common under ten years of age ; while the 
suppurative form occurs in adolescence. It occurs in both sexes. It 
may follow exposure to wet and cold, although patients who are subject 
to the attacks bear the exposure, unless at the same time they are unduly 
fatigued. The follicular form of tonsillitis is so frequently associated 
with bad drainage or other unhygienic conditions that emanations 
under these circumstances appear to be an exciting cause. Several 
persons of the same family may be affected at one time, which makes it 
often difficult to distinguish the cases from diphtheria. The disease, 
however, does not seem to be contagious. Persons brought in contact 
with the family, but who do not reside in the same house, escape the 
disease. This applies as well to children, who would, if the cases were 
diphtheritic, be more liable to become infected. The disease occurs more 
commonly in spring than in any other season of the year, but is gene- 
rally noted duriug cold and wet seasous. 

Symptoms. In follicular tonsillitis, with or without a rigor, but 
always with chilly sensations, the temperature rises rapidly to a great 
height. The subjective sensation of fever is very quickly noticeable to 
the patient, and more pronounced than in other affections generally. 
With the chill and during the rise of temperature there is some frontal 
headache, severe pain in the back and in the limbs. The pain in the back 
is most excruciating. In a short time the patient complains of the 
throat. Swallowing is difficult, and there is a sense of fulness. The 
throat is dry and burning. On examination the tonsils are swollen and 
creamy, and a yellowish-white exudation is seen on the crypts. The 
glands expand slightly, and may extend only slightly beyond the arches, 
or in younger subjects may extend one-quarter the way into the lumen 
of the fauces. Sometimes one gland is affected before the other. The 
difficulty in deglutition increases and the voice becomes nasal. There is 
usually some enlargement of the cervical glands. The general symp- 
toms continue for forty-eight hours, the temperature remains at 105°, 
and the pulse is very rapid. After the first twenty-four hours the pain 
in the back lessens. The tongue is coated, the breath is heavy. The 
urine is loaded with urates. At the end of the fifth day the fever, 
which subsided gradually, has disappeared. The local symptoms, how- 
ever, may remain longer. That is, the tonsils are enlarged and the 
exudation disappears slowly. Sometimes the prostration and general 
symptoms are very severe, so that after the fever has subsided con- 
valescence may be very slow. 

Albuminuria, due in all probability to the fever, frequently occurs ; 
in some cases, undoubtedly acute nephritis attends the attack, and it is 
the cause for prolongation of the convalescence. In a case under the 
writer's care the patient first had acute rheumatism ; this was replaced 
by a severe attack of tonsillitis, during which albuminuria, blood and 



456 



SPECIAL DIAGNOSIS. 



granular casts were found. The tonsils subsided in due course, but the 
Bright's disease continued during a long period, finally ending, however, 
in complete recovery. 

Diagnosis. The diagnostic features of acute tonsillitis are the sudden 
high fever, severe backache and headache, pain in the throat, and 
albuminuria. The characteristic appearance of the face, the salivation 
and pain, with suppressed voice and impossible deglutition, should not 
cause it to be confounded with trismus or tetanus. In both, the jaws are 
closed. It must not be confounded with smallpox, which it resembles 
during the first twenty- four hours. 

Cases of follicular tonsillitis are frequently mistaken for diphtheria. 
The inflammation in tonsillitis is limited to the glands, on which are 
patches of a yellowish-gray color, which are easily removed and do not 
leave bleeding surfaces. In diphtheria, the membrane is of an ashy-gray 
color, not in points or small patches, or separated by red tonsillar tissue. 
In diphtheria the membrane extends to the pillars of the fauces, and may 
appear on the uvula. There are, nevertheless, many cases which are 
doubtful, and bacteriological diagnosis must be resorted to (see Bacterio- 
logical Examination). The cases that particularly increase our anxiety 
are in adults who are subject to attacks of follicular tonsillitis. In addi- 
tion to the results of the bacteriological examination stress must be 
placed upon the history of exposure. In the grave and extensive 
forms of diphtheria with asthenic symptoms the diagnosis is not difficult. 

In herpetic tonsillitis, the severe pain aud intense general symptoms 
are out of proportion to the local lesion. In suppurative tonsillitis the 
constitutional disturbance is also very great. The temperature rises 
high, 104° to 105°, and the pulse is very rapid, from 110 to 130 in the 
adult. The inflammation usually begins in one tonsil first. It may be 
limited to the one side, or the other be involved later. The tonsils at 
first are enlarged and firm and very red. There is swelling of the 
tissues around. In twenty-four hours deglutition is almost impossible, 
and there is salivation. At the end of forty-eight hours the patient 
presents a striking and distressing appearance. The glands of the neck 
are enlarged, the patient is unable to open the mouth, the voice is nasal 
or almost suppressed ; there is dribbling of saliva from the mouth. 
The face may have a dusky hue in the midst of a capillary congestion 
due to the fever. There is constant desire to discharge saliva and 
accumulated secretions from the back part of the mouth. The patient 
cannot lie down. The pain is extreme, and is aggravated by swallow- 
ing. It is sometimes of a throbbing character aud often shoots to the 
ears. Indeed, the earache may be the chief pain complained of. The 
patient does not take food, aud exhaustion soon eusues. During the 
twenty-four hours before rupture takes place, on account of the exhaus- 
tion, the previously reddened face becomes blanched and dusky. The 
fever is continuous during this time, along with rapidity of the pulse. 
The patient may have been delirious. Sometimes the delirium is 
marked and the patient resists efforts to keep him in bed because of the 
intense discomfort of lying down. 

The suffering is out of proportion to the dauger of the case. About 
the fourth or fifth day suppuration has been completed, and if the finger 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 



457 



can be inserted into the mouth between the almost closed teeth, fluctua- 
tion is detected. In cases in which the mouth is opened a little more 
freely, in addition to the swelling of the tonsils below the arches, marked 
swelling and projection forward of the half-arches may be seen. The 
fluctuation may be detected through the anterior fold of the palate, and 
if lancing is to be performed pus can only be reached through this struc- 
ture. After spontaneous rupture, which usually takes place upward 
into the mouth, iustant relief is given. It may rupture into the 
pharynx, and suffocation may follow on account of the entrance of pus 
into the larynx. In rare cases it has opened into the carotid artery 
with the occurrence of sudden death from hemorrhage. 

Enlargement of the Tonsils. 

Chronic Tonsillitis. The tonsils may be enlarged on account of 
repeated attacks of acute inflammation, or attacks of chrouic inflamma- 
tion. They do not appear to be the cause of serious symptoms unless 
associated with adenoid vegetations in the naso-pharynx. They may 
interfere with hearing, however, and cause snoring at night. A fcetor 
of the breath may be noted, particularly if the secretion lodges in the 
crypts. This may be recognized by its characteristic yellowish color 
and by its odor on removal. The enlarged tonsils are irregularly formed 
and the surface is somewhat irregular. 

Foreign bodies in the tonsils are not of common occurrence. They give 
rise to local symptoms, that is, to the sensation of the presence of a mass 
causing repeated efforts at swallowing. If calculi are present the 
patient may complain of a rough body. The calculi and rough sensa- 
tions follow frequent attacks of quinsy. Hydatids are sometimes 
located in the tonsils. 

Adenoid Vegetations of the Naso-pharynx. 

While this name is applied to an abnormal increase of the tissue of 
the pharynx, other names have been given and various views held as to 
its occurrence. Some authorities have held that the vegetations were 
new growths, while others that it was simply a hypertrophy of the 
normal tonsillar tissue, the pharyngeal or third tonsil, which is situated 
in the locality in which they are found. The symptoms are due to 
stenosis of the pharynx, and are general as well as local. 

The Nose The nostrils are flattened laterally. Rarely they may be 
depressed. In one instance which the writer saw with Dr. Harrison 
Allen the exterior of the nose suggested inherited syphilis, all the 
more because of our kuowledge of the possible occurrence of the 
disease. There were no other evidences of hereditary syphilis in the 
child or in any members of his family. In a large number of cases 
there is a discharge from the nose. This may be muco-purulent, or be 
associated with crusts. If the discharge is not constant the child is 
subject to colds and discharge on the slightest provocation. Inde- 
pendent of the chronic purulent nasal discharge mucus and blood may 
be passed at night and be found on the pillow in the morning. 



458 



SPECIAL DIAGNOSIS. 



The Mouth. The mouth is kept open, and there are evidences of mouth- 
breathing. The lips are always dry and may be cracked. They are 
thickened. The dental arch is high and narrowed. 

The Voice. It is thick and muffled, becoming indistinct upon the 
occurrence of slight cold. The expression of the face is characteristic. 
It is dull and stupid, and may be drawn. 

Mental and Nervous Symptoms. Headache, listlessness, and indispo- 
tion for mental exertion are marked. The patients are usually backward 
iu their studies and are unable to fix their attention for any length of 
time upon any subject. Aprosexia is the term applied to this condi- 
tion. The child is forgetful and cannot study without discomfort. 

Choreiform spasm of the face occurs in connection with it. Enuresis 
is a frequent associate symptom. The child is subject to frequent attacks 
of indigestion. I have seen the following occur in many cases : Prior 
to operation the child had an abnormally poor appetite and was subject 
to frequent attacks of indigestion, characterized by vomiting, with fever. 
After the operation the appetite improved and continued good, and the 
attacks of indigestion disappeared entirely. The cases had been under 
observation before and after the operation for a number of years. The 
indigestion seems to have been due to the fact that on account of the 
obstruction the child would have to eat rapidly in order to keep the 
lumen of the mouth free for breathing purposes. The rapid eating, of 
course, prevented proper mouth digestion, and hence the occurrence of 
gastric catarrh. 

Symptoms of Stenosis. In addition to mouth-breathing, the patient 
snores at night, and sleep is always disturbed. The respirations are 
irregular, with a pause between, followed by noisy inspirations. The 
difficulty of breathing is the cause of restlessness, and the child will 
often waken up in the night short of breath. 

Night restlessness with dyspnoea and irregular respiration always 
point, therefore, to obstruction in the naso-pharynx. The hearing is 
frequently impaired. There may be simply dulness of hearing, or it 
may amount to marked deafness, either because of pressure of the 
adenoid vegetations or extension of secondary inflammation to the 
Eustachian tubes ; the sense of taste and smell are often much impaired. 
There is increase in the secretion of pharyngeal mucus, which in older 
persons causes difficult expectoration. 

The Appearances of the Chest While there is general lack of physical 
development, the physical development of the chest is most striking. 
The cases have been frequently mistaken for rickets, but in this country 
adenoid vegetations are a common cause of chest deformity ; whereas, in 
England and Europe rickets is the most frequent cause. The ribs are 
prominent in front, the sternum is angulated forward at the manubrio- 
gladiolar junction and grooved at the gladiolar-xiphoid junction. A 
saucer-shaped depression is found at the lower costal cartilages. The 
ribs behind are closely compressed together, so that the intercostal spaces 
at the lower part of the chest are obliterated. The chicken-breast appear- 
ance is most striking, with the depression in the lower portions of the 
chest. The diaphragm may be drawn in during inspiration in the middle 
and lateral thoracic regions. 



MOUTH, FAUCES, PHARYNX, AND OESOPHAGUS. 459 



Hhinoscopie Examination. The floor of the pharynx is covered 
with rounded or villous projections, on account of which the posterior 
nares are often concealed. Harely the villi may be seen projecting 
below the soft palate. In children the examination is difficult, and 
hence digital exploration must be used. This should be done under an 
anaesthetic unless there is no doubt whatever. The finger readily detects 
the masses, which sometimes are soft, at other times tough and of 
fibrinous or cartilaginous consistency. 

The student cannot become too familiar with the symptoms and signs 
of adenoid disease of the naso-pharynx. There is no doubt that in 
cities of this country particularly this local affection is of more common 
occurrence and more disastrous in its results than any other local affection 
that we have to deal with in children. It may be said that in children 
in poor health, ansemic, with impaired digestion, and lack of muscular 
and physical development, if the causes are not due to impure air and 
improper diet or to improper sanitation, it may be almost certain that 
there is disease of the naso-pharynx. The writer has seen a very large 
number of cases in recent years in his practice, many of whom have 
been operated on by Dr. Harrison Allen, and has had the satisfaction 
of seeing the entire picture of the child change after proper treatment. 
It may be said in passing that this change does not take place at once, 
but after three to twelve months the child will be fully restored in 
physique, if during that time attention is paid to proper exercise and 
the development of the chest. Notwithstanding all this, however, 
the natural shape of the chest and appearance of the face are only 
gradually resumed. 

Inflammations of the Pharynx. 

Inflammation of the pharynx, acute pharyngitis, or sore-throat, fol- 
lows cold or exposure, particularly after patients have been physically 
depressed ; the inflammation often involves the tonsils as well as the 
pharynx. The symptoms are pain on swallowing, with dryness and a 
constant desire to hawk and cough on account of the tickling sensation. 
There may be slight laryngitis and inflammation of the Eustachian 
tubes, with deafness. Stiffness of the neck and enlargement of the 
cervical glands attend the local inflammation. The general symptoms 
are not marked. The attack is ushered in with chilliness and slight 
fever. On examination the mucous membrane is seen to be congested, 
dry, and glistening, and covered with sticky secretion in spots. The 
uvula may be very much swollen. The acute inflammation may be 
associated with rheumatism or gout. When the submucous tissues are 
involved the parts are more swollen and there is greater dyspnoea. 
The dysphagia is more marked, although the pain is not any greater. 
The larynx is always involved under these circumstances. The fever 
is higher. 

Phlegmonous Inflammation. A diffused inflammation of this character 
occurs. The writer saw one case of this character so intense, with 
dyspnoea and high temperature, as to simulate pneumonia. Pneumonia 
was thought to be present because of the occurrence of congestion and 



460 



SPECIAL DIAGNOSIS. 



oedema of the lungs. It occurred during the prevalence of the recent 
epidemic of influenza. The disease began in the pharynx ; the tissues 
were swollen and infiltrated. The early symptoms were pharyngeal. 
The dysphagia was extreme, and there was an abundant muco-purulent 
expectoration, which did not contain pneumococci. Death took place 
from exhaustion. The autopsy showed a high degree of congestion of the 
lungs, oedernatous inflammation of the pharynx, larynx, and trachea. 
While, therefore, the recognition of an acute phlegmonous inflamma- 
tion is not difficult it must not be forgotten that it is a grave disease 
which may terminate in such marked pulmonary symptoms as to lead 
to the suspicion of pneumonia. 

Angina Ludovici is an inflammation of the cellular tissue of the floor 
of the mouth and the neck. It is probably a form of actinomycosis. 
The swelling is most marked below the jaw of one side. The symp- 
toms are very intense and both local and general. There are general 
septic symptoms at once. With the swelling there is oedema and 
board-like induration. Redness and the rapid formation of an abscess 
rarely occur. The throat is not affected. Death takes place from 
reflex suffocation or in coma (see page 449). 

Rheumatic Pharyngitis is of short duration, without objective symp- 
toms. Pain is intense, deglutition difficult. The usual concomitants of 
rheumatism are present. It frequently gives place to torticollis, 
lumbago, or rheumatism in some other situation. 

Chronic Pharyngitis follows acute attacks, or is a frequent accompani- 
ment of nasal catarrh. It is common in smokers and alcoholic subjects ; 
the use of the voice in loud tones, as by clergymen, auctioneers, etc., 
is also a cause. It is a frequent attendant upon indigestion, due prob- 
ably to the eructations. The objective signs are relaxation of the 
mucous membrane, with dilatation of the veins. The membrane is 
covered with a thick secretion, which is dry and glistening. In the 
granular form the wall of the pharynx is covered with millet-seed pro- 
jections and is congested. Tough mucus is seen in small areas. 

Retropharyngeal Abscess. The inflammation may begin in 
the submucous connective tissue, and retro-pharyngeal abscess form. 
Dysphagia with stiffness of the neck and enlarged glands, with high 
fever, are present. On examination a projection into the pharynx can 
be seen or distinctly felt on the posterior wall. The disease may be 
difficult of recognition in infants, in whom it is impossible to get a good 
view of the pharynx. On the other hand.it may be simulated by disease 
of the cervical vertebrae, in which there is also stiffness, difficulty in 
deglutition, and possibly a tumor also. It must not be forgotten that 
retro-pharyngeal abscess may result from caries of the cervical vertebrae. 
In children the abscess is attended with dyspnoea and alteration in the 
voice, so that laryngeal disease may be suspected. I recall a case of retro- 
pharyngeal abscess in which the dyspnoea was so severe as to suggest 
croup, and indeed preparations for tracheotomy were made, when sudden 
rupture of the abscess revealed the nature of the disease. Fortunately 
the child had been kept in the upright position, on account of which 
the discharge of pus came forward to the mouth, or else suffocation 
would have ensued. 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 461 



Inflammation of the Parotid G-land. 

First, specific inflammation or parotitis (see Mumps); second, symp- 
tomatic parotitis, occurs in typhoid fever, pneumonia, pyaemia, and septi- 
caemia. The process is intense, characterized by swelling, redness, and 
heat over the parotid gland. There are pain and difficulty of mastication ; 
suppuration rapidly ensues. It is thought to he an unfavorable symp- 
tom, but I have seen two cases in typhoid fever get well. In a case of 
septicaemia it did not advance to suppuration. Stephen Paget has 
described a symptomatic inflammation in disease of the abdomen and 
pelvis He collected 101 cases, 50 of which were due to injury, disease, 
or temporary derangement of the genital organs, as by slight blows ; 
or in females, the introduction of a pessary. It may occur before the 
menstrual period or during pregnancy. Septicaemia or pyaemia does 
not attend the process — indeed, many of the cases are afebrile. In 78 
cases, 45 suppurated and 33 resolved without suppuration. 

Gowers describes a case of parotitis which occurred in the course of 
fatal peripheral neuritis. 

The CEsophagus. 

The oesophagus is open to all affections which arise in mucous mem- 
branes, although its histological structure, position, and functions 
protect it from frequent involvement in disease. Should morbid pro- 
cesses arise, the symptoms expressive of these processes are the common 
symptoms of disease of the mucous membrane. But the oesophagus is a 
closed tube, the function of which is to afford entrance to and to propel 
food onward into the stomach. It is subjected to all the affections com- 
mon to channels. Any disease of the tube interferes with its function, 
made evident by the symptom common to all disorders of the oesophagus 
— dysphagia. As this symptom occupies a position of such prominence 
in the symptomatology of diseases of this tube, it is evident that diag- 
nosis of disease resolves itself into the differentiation of all forms of 
difficulty of deglutition. 

Before beginning the discussion along the lines indicated, the sub- 
jective and objective symptoms of diseases of the oesophagus must be 
considered. 

The Subjective Symptoms. Pain is a common symptom of dis- 
ease of the oesophagus. In acute inflammation it is extreme, and is com- 
plained of in the neck, between the shoulders, and along the vertebrae 
for a short distance. Its character depends upon the cause. Severe 
burning pain, often agonizing, is due to inflammation from burns or 
caustics. After the ingestion of caustics the absence of pain points to 
extreme corrosive action and gangrene. Pain attends and is part of the 
symptom — dysphagia (q. v.). Cough attends such diseases of the oesoph- 
agus as exert pressure upon the bronchus, as carcinoma. 

The Objective Symptoms. Stiffness of the neck is seen in acute 
inflammation of the oesophagus and in peri-oesophageal abscess ; it also 
may occur in traumatism. The expectation in diseases of the 
oesophagus is characteristic. It is usually a glairy mucus, often frothy 

I 



462 



SPECIAL DIAGNOSIS. 



or viscid. It is not coughed up, but after welling into the pharynx is 
hawked up. It is abundant in acute and chronic inflammation and in 
cancer. 

Hemorrhage from the (Esophagus. Hemorrhage from the oesoph- 
agus occurs from varicosity of the veins at the lower portion of 
the gullet. It may occur in old people, due to senile disease of the 
liver, kidney, and spleen, or arise as a complication in cirrhosis of the 
liver. In hemorrhage from the oesophagus the blood is usually bright 
in color, has not been acted on by the acid, and is not discharged by 
vomiting, although vomiting may occur after the blood is poured out. In 
a grave case of purpura under the care of the writer, hemorrhage took 
place from the lower end of the oesophagus. To distinguish it from 
gastric hemorrhage the stomach may be washed out. If this is done 
shortly after the hemorrhage by the introduction of a soft bougie, clear 
fluid will be discharged if the gastric mucous membrane is intact. Small 
bleedings from the oesophagus are usually indicative of cancer, if, in 
addition to the hemorrhage, there are present the symptoms of occlusion. 
Of the general symptoms due to oesophageal disease emaciation is the 
most characteristic. It is, of course, more striking in cancer, but occurs 
to a moderate degree in all forms of stricture. Foetor of the Breath. 
This usually attends dilatation of the oesophagus only. 

Emphysema of the subcutaneous connective tissue should always lead 
to the investigation of the oesophagus. Usually there have been pro- 
nounced symptoms of disease of the oesophagus. At times in rare cases 
ulceration may have gone on without symptoms. The ulceration, of 
course, extends into the air-passages with the occurrence of emphysema 
secondarily. 

Physical Examination. Examination of the oesophagus is made by 
inspection and auscultation, and by means of palpation with or without 
a bougie. The oesophagus behind the trachea in the neck may be pal- 
pated when it is enlarged as in abscess. Palpation yields the most 
positive results. Inspection can be utilized only with an endoscope. 

Auscultation of the oesophagus while the patient is swallowing fluids 
sometimes confirms the results obtained by instrumental palpation as to 
the seat of an obstruction. A gurgling sound is audible as the fluid 
passes the obstruction. 

It must not be forgotten that the normal constriction of the oesopha- 
gus is present about opposite the fourth dorsal vertebrae, ten inches from 
the teeth. The bougie is of advantage in determining the cause of the 
difficulty in swallowing. If the cause is due to paralysis, or to spasm 
of the oesophagus the bougie can usually be passed with ease. If on 
the other hand it is due to organic disease obstruction will be found. 
The obstruction in organic disease is usually in the upper half of the 
oesophagus. Near the pharynx the obstruction is due to cicatricial 
stricture. Nine inches from the teeth, or about the position of the 
bronchus, the obstruction is usually due to cancer. The bougie should 
not under any circumstances be passed if there are strong grounds for 
believing there is an aneurism. Fatal rupture has followed its passage. 

Method. The patient should be seated with the head thrown back 
sufficiently far to make the passage from the pharynx to the oesophagus 



MOUTH, FAUCES, PHARYNX, AND (ESOPHAGUS. 4(53 



almost continuous. The operator may stand behind or in front of the 
patient. The bougie should be passed through the pharynx guided by 
the fingers and kept hugging the posterior wall of the pharynx. But 
little force should be used. It should be passed slowly and will soon 
overcome the gagging. The bougie should be warmed and oiled pre- 
vious to being passed. The handles should be flexible, the bulb 
olive-shaped. 

Dysphagia is a symptom common to all diseases of the oesophagus. 
It is seen in all forms of inflammation. It may amount to simple dys- 
phagia on account of pain, or to the degree of complete obstruction of 
the tube. Dysphagia due to obstruction of the oesophagus is due 
(1) to disease outside of the canal, (2) to disease of the canal itself, and 
(3) to the presence of a foreign body in the canal. In the consideration 
of this symptom, therefore, these conditions have to be studied. 

1. The oesophagus throughout its course is in intimate relationship 
with the trachea, the thyroid gland, the carotid artery, the left bronchus, 
the bronchial glands, the arch of the aorta, and descending aorta. Disease 
of these structures which admit of enlargement are liable, therefore, to 
cause difficulty in swallowing. It is not likely that difficulty of deglu- 
tition from disease of the trachea, thyroid gland, or carotid arteries will 
be overlooked. If the trachea is affected, dyspnoea will be a prominent 
symptom ; if the thyroid gland, dyspnoea will also be associated with 
dysphagia, and the enlarged gland can be seen on the exterior. Disease 
of the vertebrae is not likely to cause obstruction in the oesophagus, for 
it would not press that organ against any other solid structure. The 
converse, however, is true : disease of the other structures causing diffi- 
culty of deglutition by pressing the oesophagus against the vertebrae. 
Within the thorax disease of the mediastinal glands and aneurism of the 
arch, or the descending portion of the aorta, enlarged left auricle or peri- 
cardial effusion, and disease of the left bronchus might cause constriction 
of the oesophagus. The mediastinal glands are enlarged from tubercu- 
losis, carcinoma, or syphilitic disease. The occurrence of physical signs 
of a mediastinal tumor, with a history of syphilis or the general symp- 
toms of tuberculosis or carcinoma, would point to the occurrence of these 
affections. In aneurism of the aorta in its arch or the transverse por- 
tion, the physical signs and subjective symptoms of aneurism, accentua- 
tion of the aortic second sound, and the presence of atheroma, would lend 
color to the view that the obstruction is of this nature. In both of the 
instances just mentioned the obstruction rarely goes to the extent of pre- 
venting the passage of liquids. In enlargement of the left auricle and 
in pericardial effusion the degree of difficulty may amount simply to a 
sense of obstruction or pain about the point where food passes these 
structures. Association of an enlarged auricle of mitral stenosis or of 
pericardial effusion with the early physical signs render the diagnosis 
of the condition easy. It is particularly important, in considering 
difficulty of deglutition from external pressure, to remember that the 
oesophagus is in close relation with the bronchus on the left side at 
about the fourth dorsal vertebra — this is ten inches from the teeth — 
in case it is desirable to investigate the obstruction with a probe. Ob- 
struction from aneurism of the descending portion of the arch of the 



464 



SPECIAL DIAGNOSIS. 



aorta is also located at the upper portion of the oesophagus, nine inches 
from the incisor teeth. 

2. Difficulty of deglutition due to disease of the oesophagus occurs in 
acute inflammation, in chronic inflammation, and in stricture, which is 
always the result of traumatic inflammation, of syphilis, or of cancer. 

Acute inflammation is recognized by severe pain on swallowing. There 
may be tenderness on pressure along the course of the pharynx, and a 
feeling of a node in the lower portion of the throat. The pain is aggra- 
vated by speaking. The pain may extend along the vertebral column 
to the cardiac end of the stomach, and is usually of a burning or raw 
character. When the inflammation is due to traumatism, as to the swal- 
lowing of acids or other caustics, the mouth and pharynx show the 
effects of the inflammation, and in addition there is agonizing, burning 
pain at the root of the neck and between the shoulders. The inflam- 
mation is usually attended by erosion of the mucous membrane, and 
hence not only frothy mucus of a glairy character is expectorated, but 
also blood and shreds of membrane. The effect of the corrosive pois- 
oning on the general system is marked. There is great prostration. 
Because of the accompanying gastritis there is intense thirst. Acute 
inflammation of the oesophagus may end in ulceration or in complete 
cure. The traumatic inflammation is followed by chronic inflammation, 
which ultimately results in stricture. 

Chronic inflammation is attended by pain in the act of swallowing ; 
viscid mucus is expectorated, usually in large amounts. Liquids are 
swallowed readily, but solids with great difficulty. 

Abscess of the (Esophagus. The acute inflammation may terminate 
in abscess. Usually an abscess develops slowly, attended with pain on 
swallowing, increased by movements of the neck. When the abscess is 
high up in the gullet it may be seen on the exterior of the neck. If 
situated outside of the oesophagus and secondary to disease of the verte- 
brae, it is slow and chronic in its course ; fever and rigors attend its 
development. 

Stricture of the (Esophagus due to the healing of ulcers fol- 
lowing traumatic inflammation is recognized, first, by the gradual 
development of the symptom, by the painless nature of the obstruction 
in the large majority of the cases, and by the seat of the obstruction. 
It is readily found if the tube is passed, or the patient can localize the 
area in the upper portion of the oesophagus. The difficulty of degluti- 
tion continues over such a long period of time that the nutrition is but 
slowly interfered with, but gradual emaciation with coincident anaemia 
sometimes develop. 

Carcinoma of the (Esophagus. In cancer of the oesophagus, 
dysphagia is the most prominent symptom. It comes on gradually. 
The patient expectorates a considerable quantity of frothy mucus, often 
of blood, and on careful examination cancerous tissue may be found. 
Pain is not generally very severe. Cough is usually present, due to 
pressure of the cancerous mass on the recurrent laryngneal or pneumo- 
gastric nerve. Sometimes the cancer appears behind, and ulcerates into 
the trachea or bronchus. When this complication takes place the cough is 
violent. Dyspnoea from pressure is likely to occur. In the course of 



MOUTH, FAUCES, PHARYNX, 



AND (ESOPHAGUS. 



465 



cancer perforation of the oesophagus into the air-passages may take 
place with the occurrence of abscess and gangrene, or with dyspnoea 
and the onset of aspiration pneumonia. 

The difficulty of deglutitiou due to cancer must be distinguished from 
traumatic or syphilitic stricture and from spasmodic stricture and par- 
alysis of the oesophagus. The history of the case aids in the recognition 
of the former, while in spasm or paralysis the passage of the tube would 
point to the condition of the oesophagus. Cancer usually occurs late in 
life and is attended with rapid emaciation. The complications which 
ensue are attended.with fever and rapid prostration. The cancer may be 
distinguished from disease outside of the oesophagus by the condition of 
the stomach beyond the point of stricture. If there is cancer, atrophy 
is more likely to take place, the diminution in size being recognized by 
a tube or by inflating the stomach with air or fluids. 

3. Stricture or difficulty of deglutition from foreign bodies is usually 
recognized with ease. In the first place there is present a history of the 
swallowing of a foreign material. Sudden pain succeeds the act, while 
there is great anxiety and distress, particularly if the body is a large hard 
mass. Not only is there difficulty in deglutition, but also dyspnoea. The 
latter is due to pressure, but aggravated by the nervous state. When 
the foreign body is small the dysphagia is moderate in degree and the 
reflex irritation slight. If it cannot be removed ulceration and abscess 
take place, the further course of which depends upon the seat of the 
obstructing material. 

Dilatation of the (Esophagus. Primary dilatation of the 
oesophagus is an extremely rare affection. The chief symptom is the 
regurgitation of food which is neutral or alkaline, and which may be 
returned some time after the act of swallowing. The patient sometimes 
complains of a sensation of distention along the course of the oesophagus, 
with heat and burning. The odor of the breath is foetid. If the 
oesophagus is not deflected a bougie can be passed throughout its course. 

If the dilatation is secondary the amount of dysphagia depends upon 
the obstruction. Food, however, is not returned immediately. After 
remaining an indefinite time, not longer than two hours, it is regurgi- 
tated unchanged. Bougies of course do not pass. In sacculated dilata- 
tion, which usually takes place in the posterior wall near the pharynx, a 
bougie may sometimes pass, and at other times may be caught in the sac. 
The sac may be enlarged so as to retain a considerable amount of food, 
which is regurgitated some time after it is swallowed. The sacculated 
diverticulum from traction on the outside of the oesophagus may occur 
when there is glandular disease of the neck with adhesions to the 
oesophagus. Traction occurs with the formation of the diverticulum. 

Functional Affections of the (Esophagus. They are quite 
as common as organic disease of the oesophagus. The functional affec- 
tions are of longer duration and unattended by grave effects upon the 
general system. Spasm is one of the most frequent affections. It may 
be so intense as to lead to stricture of a temporary character. It usually 
occurs in women. The attack comes on suddenly during the act of 
swallowing food. The food is at once regurgitated. After the sub- 
sidence of the perturbation that attends the attack swallowing can be 

30 



466 



SPECIAL DIAGNOSIS. 



accomplished if the act is done slowly. It usually occurs in hysteria. 
The patient may have had some slight accident in the performance of the 
ordinary acts of deglutition which gave her the idea that she could not 
swallow. In consequence the further acts are performed with trepida- 
tion, and from slight emotional disturbance at the table sudden spasm 
takes place. The repetition of such spasm once or twice would be 
followed by a long regime of treatment. Unfortunately attention to the 
act of swallowing always embarasses it, and the taking of a meal under 
unusual circumstances is sure to be attended by complete dysphagia. 
Sometimes the idea is conceived that certain forms of food alone cannot be 
swallowed. It is usually solid food that is thought to give the distress. 
Mitchell says that the dysphagia occurs early in cases of hysteria; unless 
relieved the manifestations are likely to be transferred to the stomach. 
I saw a female patient who, after an ordinary choking attack could not 
swallow food if it was partaken in the presence of strangers or after the 
slightest emotional disturbance or hurry. The spasm disappeared after 
treatment with bougies. 

In paralysis difficulty of deglutition is the main symptom, the course 
of which depends upon the cause of the paralysis. The larynx is 
usually affected at the same time, so that laryngeal symptoms are pres- 
ent. Paralysis generally comes on very gradually. It may be due to 
cerebral hemorrhage and tumor, and occurs in general paralysis of the 
insane and in bulbar paralysis. The bougie passes easily and does not 
cause irritation. In paralysis there is no regurgitation of food. 



CHAPTER V. 



DISEASES OF THE STOMACH, INTESTINES, AND PERITONEUM. 

In the succeeding chapters diseases of the organs within the abdomen 
will be discussed. The subjective symptoms that attend diseases of the 
various organs call the attention of the observer to this portion of the 
trunk — the abdomen. Examination of the abdomen is made with a 
view to ascertain the special organ affected. It is proper, therefore, 
before a consideration of the diseases of each organ, to discuss the 
examination of the abdomen as a whole and the subjective symptoms 
referable to this region. It will be profitable to consider the topo- 
graphical anatomy of the abdominal organs when the diseases of each 
are considered. 

The abdomen is divided into various regions by vertical and trans- 
verse lines for the localization of organs or of disease. Unfortunately, 

Fig. 76. 




The quadrants of the abdomen. 



the regions do not afford limitations for organs in health. Moreover, 
the regions are arbitrary, the boundaries differently constructed by 
various observers, and both are grasped with difficulty by the student. 
Simplicity should hold in these matters, and, moreover, a method of 
delimitation that is commonly used in the subdivision of other regions 



468 



SPECIAL DIAGNOSIS. 



should be adopted, to add ease of remembrance and uniformity of 
description. For these reasons, and because, as a teacher, I have seen 
the difficulties of students, the method of marking the surface pre- 
pared by Ballance appealed to me. This author includes the abdomen 
within a circle, with the umbilicus for its centre. The circle is 
divided into quadrants by diameters drawn at right angles, corre- 
sponding to the median and transverse umbilical lines. The portions 
to the right of the middle lines are the right upper and lower quad- 
rants respectively ; the portions to the left, the left upper and lower 
quadrants. 

With the abdomen thus divided, the umbilicus and fixed bony 
structures in the periphery of the circle serve as points from which 
measurements are made to indicate the exact position of the structure 
the seat of which is to be recorded. The circle may be divided by 
other radii. To locate a tumor in the right lower quadrant, for in- 
stance, the umbilicus, pubic bone, and anterior spine of the ilium may 
be used as points from which to measure the distance. Measurements 
may also be made along radii extending from the umbilicus to fixed 
points. The following is a useful method : A tumor is situated in the 
right lower quadrant ; the centre of the tumor is two inches below a 
point on the transverse umbilical line, three inches from the centre; it is 
also three inches to the right of a point on the median line, two inches 
from the umbilicus. The size of the tumor can be defined by measure- 
ments from its centre. Organs bisected by the median line, as the 
bladder and uterus, can be described as situated in the median line, as 
many inches to the right and left as it may be, and the number of 
inches from the pubis given. 

Included in the right upper quadrant, the right lobe of the liver, 
the gall-bladder, pylorus, transverse colon, a portion of the pancreas, the 
pyloric orifice near the median line, and deeper, the upper half of the 
kidney would be found ; in the left upper quadrant, the left lobe of the 
liver, the stomach, the pancreas, and upper portion of the kidney and 
the spleen ; in the right lower quadrant, the csecuru, appendix vermi- 
formis, right tube and ovary, a portion of the bladder and uterus, and 
above, the lower part of the kidney ; in the left lower quandrant, the 
corresponding tube, ovary, and portions of the bladder and uterus, the 
sigmoid flexure of the colon, and the lower part of the kidney; about 
the centre and extending to the periphery on all sides, the small and 
large intestines. 

The Data Obtained by Inquiry. The Subjective Symptoms 
of Abdominal Disease. 

This class of symptoms will be discussed in the articles devoted to 
affections of the particular orgaus of the abdomen, because the symp- 
toms are usually directly referred by the patient to the affected organs. 
They are local sensations of heat, fulness, or distention, of burning, of 
weight, or of undue motion. Local sensations of weight, fulness, or 
distention, are due to enlargements or to displacements of organs (liver, 
kidneys) or to tumors. Heat or burning is described in inflammatory 



STOMACH, INTESTINES, AND PERITONEUM. 469 



tumors, as pyosalpinx. It is often difficult for the sufferer to define the 
location of pain in the abdomen and describe its features. Moreover, the 
pain is frequently due to disease of the walls of the abdomen, a location 
which may cause confusion in the recognition of its true source. Pain 
must be investigated by an examination of each anatomical structure in 
relation to the part complained of as painful. The state of the function 
of each organ must be inquired into. 

Pain due to Disease of the Structures of the Abdominal Walls. The 
skin, the nerves, the muscles and fascia, the connective tissue, may be 
the seat of the pain. If the skin is affected the pain is usually local- 
ized, not severe, and there are evidences of inflammation, as erythema, 
or ulcers, and there is superficial tenderness. Pain due to affections of 
the nerves is seen in herpes zoster and is recognized by the course of the 
pain and its attendant eruption. Neuralgias are recognized by the 
well-known points of tenderness, the intermittent character of the pain, 
and the association with anaemia ; neuritis may be present, with the ob- 
jective signs. A common cause of pain in the abdomen is due to disease 
of the vertebrae pressing upon the peripheral nerves at their emergence 
from the spinal column. It is situated in the median line, either below 
the ensiform cartilage or around the navel; it is an intermittent pain. 
Aneurism of the abdominal aorta with pressure and erosion causes the 
same character of pain. The muscles and fascia may be the seat of 
rheumatic inflammation, causing severe pain. The muscles may be 
tender. Movement always increases the pain, and sighing, laughing, or 
coughing may aggravate it. The pain may be so diffuse and severe as 
to lead it to be confounded with peritonitis. The presence of rheu- 
matism in other muscles, of moderate fever without gastro-intestinal 
disturbance, of uric acid and urates in excess due to the rheumatic 
diathesis, points to the true condition. 

The seat of the pain will be considered in discussing special organs or 
diseases of the individual organs. In general it may be said the seat of 
the pain is a fair index of disease of some structure in the part indicated. 
When the pain is general it points to rheumatism or to peritonitis. 

Character of Pain. Pain in the abdomen may be acute or may continue 
over a long period of time. Acute pain points to inflammation, to per- 
foration, to gastralgia, to enteralgia, or to occlusion of channels, of which 
the abdomen contains so many ; chronic pain, to ulcer, to chronic pro- 
cesses, or to gastric or intestinal neurosis. Attacks of pain may be 
sudden in onset, or, in severe type, may be the result of a gradual 
increase of pain,beginning in slight sensations of discomfort. 

Mode of Onset. Attacks of sudden pain are spoken of as colic ; the 
onset is sudden ; the pain is paroxysmal ; each spasm of pain is attended 
by vomiting, rapid pulse, cold extremities, cold sweat, and more or less 
collapse, except in lead colic. Such pain is seen in intestinal colic, hepatic 
colic, renal colic, uterine and vesical colic. 

Sudden pain occurs in perforation of some one of the hollow viscera, 
its seat being ascertained by the history of the disease prevailing at 
the time, the location of the disease, and the character of the symp- 
toms attending the pain. Thus perforations of gastric ulcer may have 
occurred in the course of the disease, the symptoms of which were 



470 



SPECIAL DIAGNOSIS. 



previously present. The seat of the pain would point to its source, 
and the occurrence of vomiting aid in detecting its origin. 

The Data Obtained by Observation. The Objective Symptoms. 

The examination to determine objective symptoms of disease within 
the abdomen is made by the usual methods. Changes in the appearance 
of the abdomen are caused by disease of structures adjacent to the 
abdomen, or remote from it, as the lungs or heart, or the brain. Dis- 
ease or paralysis of the diaphragm alters the movements of the abdomen 
in respiration and the appearance of the upper half. Fluctuating changes 
in size occur in hysteria and gastric neurasthenia and permanent change 
in tuberculous meningitis. The objective signs are observed by the 
usual methods. 

Inspection. In general inspection of the abdomen, attention should 
be directed, first, to the size and shape ; second, to the color and to the 
presence of normal or abnormal markings ; third, to pulsations and unusual 
movements of some of the viscera, to the condition of the abdominal 
walls and the appearance of the veins. Increase in size may be general 
or heal. 

The abdomen differs very much in size in different persons, depend- 
ing not only upon the thickness of the fat in the abdominal walls and 
omentum, but upon the calibre of the intestines themselves, which are 
apt to be much distended in those accustomed to eat large meals. In 
general, the belly is more protuberant in infants and children than in 
adults. 

General Enlargement of the Abdomen. This occurs in 
obesity, and it is often difficult to tell whether the excessive deposit of 



Fig. 77. 




The shading indicates the position ot the percussion dulness in a case of ascites, while the 
patient is lying on the hack, the fluid falling to the low levels in the flanks, and the umbilical 
region remaining clear. (Finlayson.) 

fat in the abdominal walls and omentum accounts for the whole enlarge- 
ment or only serves to mask the presence of a tumor. Enlargement 
of the belly from obesity is only a part, though frequently the most 
pronounced evidence of obesity, whereas, in enlargements of the abdo- 



STOMACH, INTESTINES, AND PERITONEUM. 471 



men from other causes than flatulency, such as tumors and ascites, there 
is usually a marked contrast between the size of the abdomen and that 
of the rest of the body. 

In enlargement from ascites, when the patient is lying upon his back 
the front of the abdomen is flattened, while the flanks bulge. If he turns 
upon his side, the flank which is uppermost becomes hollowed out and 
the front of the belly is prominent. This is the appearance in moder- 
ately large effusions which have existed long enough to stretch the lateral 
abdominal muscles. When the effusion is enormous, all parts of the belly 
are distended, and the appearance of the abdomen is then barrel-shaped ; 
and no change of shape occurs upon change of posture. (Fig. 77.) 

Enlargement from accumulation of gas within the bowels is general, 
and may attain a very high degree, giving the abdomen, a uniform 
arched appearance resembling a barrel. The diaphragm may be pressed 
upward so far as to interfere seriously with respiration and heart action. 
Moderate degrees of distention from gas in the intestines may be the 
result of eating certain articles of food, such as turnips or beans. Ex- 
cessive accumulations are met with in typhoid fever ; peritonitis, opera- 
tive and non-operative ; and in stenosis of the colon or rectum from any 
cause. They are also common in hysteria. 

In the last month or two of pregnancy enlargement of the abdomen 
is general, especially in a woman who has previously borne children. 

General enlargement of the abdomen may be due also to cancer of 
the peritoneum, to hydatid cyst, and to cancer of the bowel. It has 
been observed in children in dilatation of the colon. The abdomen was 
uniformly enlarged in Hughes' case and in Osier's cases. Coils of the 
intestine, with waves of peristalsis were seen through the thin abdom- 
inal walls. Formad's case occurred in an adult. The distention was 
enormous. Constipation attended all these cases. 

Other causes of abdominal enlargement are diseases of the liver and 
gall-bladder. When these are considerably enlarged a local swelling 
may be detected in the right upper quadrant; but when they attain 
very large dimensions, as happens not infrequently in cancer, amyloid 
disease, and hydatid liver, inspection may be able to detect only general 
enlargement, with small ' prominences corresponding with cancerous 
nodules or small cysts. 

Splenic enlargements, which attain the greatest size, are from leukemia 
or chronic malarial poisoning, and are usually visible only as general 
enlargements of the belly. There may, however, be greater prominence 
over the lower left ribs and in the left upper quadrant posteriorly. 

In diseases of the kidney producing great enlargement there is usu- 
ally visible a prominence in the lateral and lumbar region of the kidney 
involved, unless there is considerable emaciation, but anteriorly the en- 
largement, if any be visible, usually appears to be general. 

Enlargements of the abdomen which begin in the lower quadrants are 
usually of pelvic origin. The most common are those due to pregnancy, 
cysts of the ovary or parovarium, fibroids and fibro-cysts of the uterus, 
and abscesses or effusions (chronic peritonitis). A greatly distended 
bladder may cause confusion ; it is a good rule to be sure that the blad- 
der is empty, by haviug a catheter passed, before proceeding further 



472 



SPECIAL DIAGNOSIS. 



with the examination. Intestinal peristalsis is observed in constriction 
of the bowels. The motion of the intestine above the seat of stricture is 
wave-like or worm-like, and the bowel itself dilated. 

Local Enlargement, or Tumors of the Abdomen. In the 
space below the xiphoid cartilage and between the ribs (epigastrium), 
local enlargements may be due to a distended or dilated stomach, or to a 
tumor of the pylorus, which is almost always cancerous. But enlarge- 
ment in this region is sometimes due to cysts, sclerosis or cancer of the 
pancreas, to aneurisms, to cancer of the large intestine or the left lobe of 
the liver. It is in this region or to the left of the median line and 
nearer the umbilicus that the effusions into the lesser peritoneal cavity 
are found. 

A rigid rectus muscle is capable of simulating a tumor, and in hys- 
terical subjects when associated with tympanites has received the name, 
phantom tumor. Such swellings are less constant in their shape and 
character than genuine tumors, and while dull on percussion, may be 
detected to be more superficial; they sometimes disappear under friction, 
and certainly under full anaesthesia ; nervous symptoms are present and 
decided effect upon the health absent. 

Enlargements in the right upper quadrant (right hypochondrium) are 
most frequently due to diseases of the liver (which see), and to affections 
of the gall-bladder. But less frequently a much enlarged kidney or a 
hydronephrosis causes swelling in this region. The differential diag- 
nosis is made by the history of the case and by noting the direction in 
which the tumor has grown, by examination of the urine, and by the 
relation which the ascending colon bears to the tumor; kidney tumors 
carry it in front of them as they grow; hence their dulness is obscured 
by the superficial tympany of the colon. 

Enlargement in the right lower quadrant (right iliac region) is most 
frequently due to affections of the caecum and appendix, to tumors of 
the ovary, and to pelvic abscesses. 

The diseases of the cmcum and appendix causiug enlargement in the 
right iliac fossa are faecal accumulation, typhlitis, faecal abscess, peri- 
typhlitic abscess, and stricture of the ileo-caecal valve. 

The diseases of the ovaries aud tubes causing enlargement in this 
region are ovarian tumors, cysts of the broad ligament, pelvic abscess 
(usually tubal in origin), and extra-uterine pregnancy. 

Other affections which need to be considered are tubercular peri- 
tonitis, acute and chronic, and rare instances of disease of the kidneys 
or spleen with considerable enlargement. 

Enlargement in the left upper quadrant (left hypochondriac region) 
is due to dilatation or carcinoma of the stomach; enlargement of the 
spleen, movable kidney, or tumors of the kidneys, and effusion in the 
lesser peritoneal cavity. Enlargement in the left lower quadrant (left 
iliac region) is due to tumors (cancerous) of the sigmoid flexure and to 
the tumor due to volvulus, and causes of enlargement of the right side 
which are possible on the left. 

Enlargement about the centre of the abdomen (umbilical region) may 
be due to umbilical hernia, to a floating kidney, spleen, or liver, or to 
tubercular disease of the omentum or mesenteric glands. This region 



STOMACH, INTESTINES, AND PERITONEUM. 



473 



is frequently enlarged in conjunction with a more prominent swelling 
extending from the sternum in cancer of the stomach, from the ribs on 
the right in cancer of the liver or gall-bladder, or other disease of these 
viscera, the ribs on the left, in effusions into the lesser peritoneal cavity, 
disease of the pancreas or the spleen. Undue projection of the vertebrae 
must not be mistaken for tumors. 

Enlargement above the pubis (hypogastric region) is due most fre- 
quently to enlargement of the uterus, from pregnancy, fibroid tumors, 
or fibro-cysts, or to distention of the bladder. 

Enlargement in the lateral regions and behind {lumbar region) occurs 
in malignant tumors of the kidney, in hydro- and pyo-nephrosis, in 
peri-nephritic abscess, and in renal cysts of large size. It may also, in 
the left side, be due to perigastric sub-diaphragmatic abscess, and to 
enlargement and displacement of the spleen. On the right side the 
cause may be enlargement of the liver or a hydatid cyst. 

Diminution in Size. The abdomen is diminished in size in wast- 
ing diseases, or such as result in insufficient food being taken. Among 
this class come cancer of the oesophagus and stomach, chronic lead- 
poisoning, anorexia nervosa, and chronic diarrhoea and tuberculosis of 
childhood. In tubercular meningitis in children there is retraction of 
the abdomen in the second stage. The wasting of the subcutaneous and 
the omental fat, and atrophy of the abdominal organs, cause the abdo- 
men to be concave or scaphoid. 

The Shape. In general enlargements the shape is uniform. In 
large accumulations of fat in women with relaxed abdominal walls the 
abdomen may be pendulous. In ascites the tissue over the umbilicus 
may protrude, changing the uniform appearance. In local enlargements 
the surface is often irregular, corresponding to the seat of the enlarge- 
ment. The shape changes in hysterical distention. In enlargement due 
to wasting disease of the viscera, as cancer of the retro-peritoneal glands, 
the abdomen retracts in the later stage of the disease, causing undue 
prominence of the viscera affected by carcinoma. 

The Color. The abdomen, in general, partakes of the hue of the 
skin of the body. It is darker around the umbilicus. In Addison's 
disease a distinct areola often forms. The median line, from the um- 
bilicus to the pubis, darkens in pregnancy — the " brown line." It is 
sometimes seen in men. The skin of the abdomen is the seat of specific 
eruptions, as in typhoid fever, and of sudamina. The walls may be 
pale and glistening in oedema. 

Markings. In first pregnancies and great ascites, less frequently in 
obesity and tumors, strim are produced in the parts of the skin where 
the tension has been greatest. In pregnancy they form sinuous lines 
upon the lower lateral portions of the abdominal wall and upon the 
upper inner portions of the thighs. When first developed they are 
reddish, but subsequently become, by a process of fading, more glisten- 
ing and white than the rest of the skin. They are also known as 
" water lines," or linear albicantes. 

The Movements. (See the Lungs — Dyspnwa.) The upper zone 
participates in respiratory movements, especially in males. In enlarge- 
ment of the abdomen and in upper abdominal tumors, the movement is 



474 



SPECIAL DIAGNOSIS. 



restricted. Abdominal pulsations are observed. The liver may be the 
seat of pulsation. The region below the sternum (epigastrium) is a 
common seat, but pulsation may occur anywhere in the course of the 
aorta. (See Epigastric Pulsation, p. 368.) 

Peristaltic movement may be seen through the abdominal walls. It 
may occupy the large or the small intestine. If the large intestine, the 
waves are confined to the seat of this canal ; if the small intestine, to 
the region around the umbilicus. It is always due to obstruction of the 
lumen of the bowels. It is also seen in dilatation of the stomach. Pul- 
sation of the liver may occur. (See Dilatation of Heart.) 

The Veins. Enlargement of the superficial veins is a common accom- 
paniment of cirrhosis of the liver, and stasis of the portal circulation, 
as well as of any cause which obstructs the free circulation in the infe- 
rior vena cava. Occasionally a varicose condition of the veins about 
the umbilicus is seen (caput Medusce). 

General Palpation and Percussion of the Abdomen. Pal- 
pation and percussion in diseases of the abdomen may be discussed 
together. Generally the best position is the recumbent one, because it 
admits of examination without too great exposure, and because in that 
position the abdominal muscles are partly relaxed. When the muscles 
need to be still further relaxed the patient should lie upon the back with 
the head aud thorax partly elevated and the knees drawn up. The ex- 
amining hand should be warm, as the application of a cold hand throws 
the abdominal muscles into involuntary contraction. In certain obscure 
tumors much can be learned by having the patient rest on the hands and 
knees, or assume a knee-chest position. By this means we can deter- 
mine if the pulsation is due to aneurism or to a tumor. The latter falls 
away from the vessels, and lessens pulsation thereby in the position just 
mentioned. A tumor surrounded by coils of intestine may be more 
palpable. 

Moreover, by grasping the abdominal walls between the thumb and 
fingers their thickness and the relative proportion of fat can be esti- 
mated. So, too, the presence or absence of oedema of the skin can be 
readily detected. This oedema is general, but especially marked in the 
lateral and posterior portions of the abdomen. Relaxed abdominal 
walls occur after dropsy and pregnancy. Redundant skin remains in 
folds when pinched up. This is particularly so in abdominal cancer. 

When it is desired to explore deeply the patient should be instructed 
to breathe with the mouth open, and the examining hand pressed firmly 
in during respiration, and held there, if need be, during several long 
breaths. The same procedure is adopted when we desire to get the 
percussion note of a body lying deep in the abdomen : the finger is 
pressed firmly and deeply in, and then percussed. In this way any 
superficial resonance due to overlying intestine is eliminated. 

When palpating to determine the lower edge of the liver or spleen, 
the palmar surface of the fingers is pressed into the abdomen at different 
levels from below upward until the edge is felt. The edge of the right 
lobe of the liver in its normal position extends to the margin of the 
ribs. It may be detected by pressing the fingers in as described and 
having the patient take a long breath. 



STOMACH, INTESTINES, AND PERITONEUM. 475 



By palpation, the facts derived by inspection are confirmed ; the 
character of the abdominal walls and of swellings determined ; the 
precise location of pain ascertained ; the condition at the hernial rings, 
and the movability of tumors inquired into. The condition of the 
integument should first be determined. Passing the hand gently 
over it is sufficient to decide whether it is normally smooth and 
elastic, or harsh and dry. Any marked unevenness, such as are pro- 
duced by umbilical and inguinal hernise, striae, or by large tumors 
of the pylorus, or cancerous nodules and hydatid cysts of the liver, 
can readily be detected. The degree of tension of the abdominal walls 
is easily appreciated. It is increased, of course, in all forms of great 
enlargement, but not equally ; and some persons are so sensitive to 
touch that any attempt at palpation throws the abdominal muscles 
into such rigid contraction that examination is impossible. Rigidity of 
the abdominal walls may be the only sign of acute peritonitis. It is 
common in local peritonitis. The recti muscles contract quickly on 
hurried palpation. Local contractions point to inflammation underneath. 
In tuberculous peritonitis we see distention with board-like rigidity or 
preternatural hardness. The term carreau is applied by the French to 
this condition. Peritoneal friction may be detected most frequently 
over the liver and in chronic peritonitis. 

Palpation and Percussion of the Lower Quadrants. On 
the right side, the groups of affections connected with the caecum and 
appendix, the uterine appendages, and the peritoneum, which cause 
enlargement in this region, have been mentioned already under local 
inspection of the abdomen. Palpation and percussion, however, are the 
methods which afford exact information of their physical characteristics 
and, with the clinical history, enable us to differentiate one from the other. 

Diseases of the Appendix and Casenm. The information supplied by 
palpation and percussion in perforation of the appendix will depend 
upon the rapidity with which perforation has supervened and upon 
the stage at which the examination is made. 

Speaking generally, following the sudden onset of pain in the right 
iliac fossa in a person previously in good health, tenderness on palpa- 
tion in this region is felt. This tenderness is first localized, but may 
spread with great rapidity over the whole abdomen. Subsequently, 
the tensiou in the part is increased, the percussion resonance impaired, 
and there may be a gurgling sound on pressure with the hand. Ex- 
amination with the finger in the rectum may discover the presence of a 
tense, swollen appendix, or of a tumor in the pelvis. 

But the disease may be fulminating in character, perforation being 
followed by the rapid development of peritonitis, with collapse, so that 
when the patient is seen there will be no more tenderness over one part 
of the abdomen than another. 

Again, the appendix may be subject to repeated attacks of inflamma- 
tion without perforation, but with the development of local peritonitis. 
There is increased thickening in the region of the caecum, tenderness, 
diminished resonance, and increased resistance to the percussed finger. 
Sometimes an enlarged and hardened appendix can be made out by 
palpation, both during an attack and in the intervals. 



476 



SPECIAL DIAGNOSIS. 



In still other cases, of slower development, a distinct perityphlitic 
abscess develops. In addition to local pain and tenderness, a swelling 
appears above Poupart/s ligament. The skin over it becomes brawny 
and pits on pressure with the finger-tips. The tumor is dull on percus- 
sion, and on palpation obscure deep-seated fluctuation can be obtained. 
A fluctuating tumor can also be made out by rectal examination with 
the finger. 

In fcecal impaction of the ccecum a tumor forms, following the course 
of the caecum and being directed upward from Poupart's ligament. It 
is usually oblong and rounded, and may be uneven or lumpy on closer 
palpation ; it is not tender unless the caecum itself becomes inflamed. 
It has a doughy consistency. 

The diagnosis is made by the situation and character of the tumor, 
the absence of pain, tenderness, and constitutional symptoms, and by 
its disappearance under the influence of purgatives. 

In typhlitis a sausage-shaped tumor is found lying above Poupart's 
ligament and running upward from it. It is frequently the result 
of faecal impaction of the csecum. The tumor is tense, tender, and 
painful, dull on percussion, the dulness being sharply limited by the 
boundaries of the caecum. 

In intussusception a tumor is often detected in the right lower quad- 
rant or to the right of the navel. It is generally distinct, of the shape 
of the bowel, not very tender, and harder than the tumor of appendicu- 
lar inflammation. The diagnosis from the latter is made by the difference 
in the character of the tumor, by the pain being colicky and recurring 
in paroxysms, by vomiting and constipation being more marked, and 
by the passage of blood and mucus from the bowel. The last named 
and the tumor, with a coustant desire to defaecate, are the most charac- 
teristic symptoms. A tumor may be detected within the rectum by 
digital exploration, if the intussusception is low down. There may be 
distinct hemorrhage, or the passage of the invaginated portion of the 
bowel per rectum. Intussusception is the most frequent cause of 
intestinal obstruction in infants and young children. It occurs nearly 
twice as often in males as in females. Stercoraceous vomiting is not so 
common as in other forms of acute obstruction of the bowel. The affec- 
tion is of short duration, ending in recovery or death, usually within a 
week. Exceptionally, life may be prolonged for a much longer time. 

In pelvic abscess a swelling sometimes makes its appearance on the 
right side above Poupart's ligament. It is, perhaps, situated more to- 
ward the median line than perityphlitic abscess, and it is less defined 
than the tumor of typhlitis; but the diagnosis from these affections 
must be made by the history, which is usually that of an antecedent 
salpingitis, or of previous abortion or miscarriage. Vaginal examina- 
tion discovers that palpation of the uterus causes pain ; that the uterus 
is fixed in position, instead of being freely movable ; and that the pelvis 
is blocked up by an exudate on the affected side. 

In pelvic hematocele a tumor may form and be discovered in the 
lower half of one of the lower quadrants. It is distinguished from 
appendicitis, perityphlitic abscess, and pelvic abscess by the absence 
of fever and constitutional signs of suppuration ; from perityphlitic 



STOMACH, INTESTINES, AND PERITONEUM. 



477 



and pelvic abscess by its sudden onset, probably at a menstrual period ; 
by the less degree of tenderness ; by the anaemia and collapse which 
have followed its appearance. It is almost invariably the result of a 
ruptured extra-uterine pregnancy. From pelvic abscess it is distin- 
guished by its occurrence in a woman without antecedent tubal or 
uterine disease, and by the less degree of tenderness of the uterus and 
relative absence of fixation. 

In stricture of the ileo-ccecal valve due to cancer there is frequently a 
tumor in the right lower quadrant between the umbilicus and anterior 
superior process of the ilium, or the latter and the ribs. The diagnosis 
is made by noting the fact that the tumor has developed gradually, 
that the patient has suifered with colicky pain, vomiting and constipa- 
tion, possibly preceded by diarrhoea, and that peristaltic movements of 
the intestines can readily be seen through the abdominal walls. The 
abdomen at the site of the tumor is somewhat distended. The tumor 
itself is irregular and tender, and is dull on percussion. 

The disease is very rare, and is said by Fenwick to be more common 
in women from twenty to forty years of age. 

Fcecal abscess, arising from ulceration of the colon, may be suspected, 
according to Fenwick, when there is a localized abdominal swelling, 
immovable in respiration or by a moderate amount of pressure with the 
fingers, the size and shape being altered when diarrhoea occurs, and when 
percussion over the tumor gives a tympanitic or a more forcible stroke, 
a dull sound, or when an emphysematous sensation is communicated 
to the fingers. 

In tumors of the right ovary there is at first a gradual enlargement in 
the right groin, unaccompanied by pain, fever, or impairment of health 

Fig. 78. 




Position of an ovarian tumor of the right side, in various stages of enlargement. The shading 
indicates the percussion dulness in ovarian dropsy of moderate extent: the umbilical region is dull, 
from the presence of fluid, and the flanks remain clear. The outer circle shows a further extent 
to which the dulness may reach in ovarian dropsy. (Bright.) 



until the tumor has attained considerable size. They are usually cystic, 
and fluctuation can be obtained. The tumor is dull, and by bimanual 
examination with the fingers of one hand in the vagina the tumor can 
be traced into the broad ligament and the displacement of the uterus 



478 



SPECIAL DIAGNOSIS. 



which it occasions made out. The cystic ovarian tumors grow from the 
starting-point in the direction of an axis diagonally toward the median 
line. There is dulness in front of the abdomen, a clear percussion note 
or tympany in the flanks. (Fig. 78.) 

In the Left Lower Quadrant. Enlargements in this region are due 
most frequently in women to ovarian tumors, pelvic abscess, pelvic hcema- 
tocele, and fibroids of the uterus, the diagnostic points of which have been 
referred to already under palpation and percussion of the right iliac region. 
In addition to the affections named, enlargements are occasionally met 
with from faecal accumulations in the flexure of the colon, cancer of the 
descending colon, tubercular peritonitis, and enlargements or displace- 
ments of the spleen and kidney (which see). Fcecal abscess also may 
occur here, and the tumor of intussusception may be detected on the left 
side. 

Palpation and Percussion above the Pubis. Enlargements 
in this region may be due to fibroid tumors of the womb. They occur 
most frequently in sterile women, and are accompanied usually by 
hemorrhage. Bimanual examination of the uterus will be able to detect 
an unevenness of surface of the womb if the tumor is external, and 
passage of the sound will detect any growth projecting into the cavity 
of the womb. 

The enlargement may be due to a distended bladder. It is a good 
rule always to be sure that this viscus is empty before beginning an 
examination. 

In acute tubercular peritonitis a swelling may develop in this region. 
It appears gradually, is diffused and free from tenderness, but is pre- 
ceded by pain and fever. There is no palpable tumor, but the percus- 
sion note is dull and the tension is increased. Moreover, the level of 
dulness is apt to vary with change of posture of the patient. The 
general health is markedly affected, loss of flesh is rapid, and diarrhoea 
and sweats are common. Another focus of disease may be discovered 
in the lungs. 

Palpation and Percussion of the Region below the 
Sternum. Enlargement in this region is most frequently due to affec- 
tions of the stomach (which see). It is not uncommon, however, to 
find h^re a cancerous nodule projecting from the surface of the liver, or 
an hydatid cyst of the same organ. The diagnosis must be made by 
determining with the aid of palpation and percussion whether the 
tumor is continuous with the liver, the effect of respiration upon it, and 
its apparent depth from the surface, tenderness, fluctuation, etc., and by 
a study of the subjective symptoms pointing to disease of the stomach 
or liver. (See under Diseases of the Liver.) 

Much more rarely enlargement here may be from tumor of the pan- 
creas, which may be from cyst, abscess, or from cancer. According to the 
studies of Fitz, the former is marked by deep-seated colicky pain occur- 
ring in paroxysms, by discharges from the bowels of matter resembling 
saliva, by the detection of fat in the stools and sugar in the urine, by 
salivation, and by the occurrence of jaundice. 

Cancer of the pancreas is to be recognized by the detection of a 
painful tumor in the epigastrium. The pain is not aggravated by the 



STOMACH, INTESTINES, AND PERITONEUM. 



479 



taking of food, but is said to be by the erect posture. The bowels are 
constipated, and the stools may or may not be fatty. Emaciation is 
progressive, as in all cancerous affections, and in the latter stages there 
may be occasional vomiting and persistent jaundice. 

Palpation and Percussion of the Upper Left Quadrant. 
Enlargement in this region is generally due to disease of the spleen 
(which see). 

It may be due to /cecal accumulation in the left transverse and de- 
scending colon. This condition is recognized by the painlessness and 
doughy consistence of the tumor, and by careful inquiry as to the 
condition of the bowels. Constipation will, of course, exist, but both 
patient and physician may be misled by apparent diarrhoea, or even 
dysentery ; there will be fluid or semifluid dejections mingled with 
scybala, and sometimes mucus and blood. 

An interesting cause of swelling in this region, and in the lumbar 
region, is perigastric, or subdiaphragmatic abscess, a collection of pus 
walled in by the stomach, spleen, diaphragm, colon, and the abdominal 
walls. 

The most common cause is the irritation of a gastric ulcer which has 
nearly or quite perforated, and has formed adhesions with surrounding 
viscera. This was the cause in forty-one out of fifty-two cases analyzed 
by Fenwick, while in six it was associated with cancer and in four with 
abscess commencing externally. Pain in the epigastrium or abdomen 
was the chief subject of complaint, and in most of the cases there was 
dyspepsia, sometimes with vomiting. It is singular that hsematemesis 
was mentioned in only two cases. Fenwick thinks that in every case 
of perigastric abscess, except in persons affected with phthisis, cancer, 
or some other chronic exhausting malady, the first formation of the 
abscess will be accompanied by either collapse and signs of general 
peritonitis, or by sudden and severe pain in the epigastrium, attended 
with indications of local peritonitis. 

Fever is a prominent symptom, but physical signs are absent. A 
tumor, according to the same author, is rarely distinguishable except 
when the cause is cancer. It is dull, but afterward tympanitic on 
percussion, and not movable on inspiration or external pressure. The 
tension of the abdominal muscles prevents successful palpation. There 
may be arching outward of the ribs. The displacement of surrounding 
viscera will depend upon the size of the abscess and the extent of 
adhesions. But the diaphragm is pushed upward, and dulness may 
extend as high up as the angle of the scapula. In this case a pleural 
effusion is simulated. Breathing is embarrassed by the upward pressure 
of the lung and heart. Sometimes when gas is formed in connection 
with the abscess amphoric sounds on auscultation and percussion are 
heard both in the abdomen and over the thorax. To this condition 
the name pyo-pneumothorax subphrenicus has been applied. The ab- 
domen then becomes tense, tender, prominent, and tympanitic on 
percussion. 

Palpation and Percussion of the Loins. Enlargements in 
these regions are due most frequently to affections of the kidney (which 
see). They may, however, be due to enlargement or displacement of the 



480 



SPECIAL DIAGNOSIS. 



spleen and liver (which see), or to tumors of the retro-peritoneal glands. 
On the left side the possibility of perigastric abscess must be borne in 
mind, as sometimes the dulness and increased tension of the tumor 
extend as far down as the lumbar region. 

Palpation and Percussion about the Centre of the Ab- 
domen. Umbilical hernia, cancers of the stomach and liver, hydatid 
cysts of the liver, and tumors of the gall-bladder, together with floating 
kidney, spleen, and liver, all at times cause tumors which may be felt 
in this region. They must be distinguished from each other by 
methods already referred to under the organs named. The general 
principle upon which to proceed is to endeavor by palpation and per- 
cussion to discover the organ to which the tumor belongs. To this end 
also careful inquiry should be made as to the time the tumor has been 
known to exist • its effect upon the general health, if any ; its effect 
upon the function of the possible organs affected, and particularly as 
to the presence or absence of vomiting, constipation, diarrhoea, or 
jaundice. 

Tumor iu the region about the umbilicus may be from tubercular 
disease of the mesenteric glands (tabes mensenterica). It occurs nearly 
always in children, and presents the physical signs and symptoms of 
tubercular peritonitis, with the addition that enlarged mesenteric 
glands may sometimes be felt. Children grow pale and anaemic, waste 
away, have apparently causeless diarrhoea, the passages being foul and the 
food undigested. The abdomen is large, but appears larger when com- 
pared with the emaciated body. It is tender, its walls thickened, and 
less elastic than normal. Signs of tubercular disease in other organs 
may be detected. 

Facts gathered in this way, carefully analyzed, and then studied with 
reference to the physical properties of the tumor (hard or soft, fluctua- 
ting, doughy, or not), will generally suffice for a probable diagnosis. A 
positive diagnosis often cannot be made at the first examination, and 
sometimes is possible only after watching the progress of the case for a 
considerable time. 

Diseases of the Stomach. 

The stomach is a canal in which the food is detained for the purpose 
of solution. Its walls are made up of mucous membrane, muscle and 
peritoneum. It is richly supplied with bloodvessels. Because of its 
great functional activity it has an abundant nerve supply. It is, more- 
over, surrounded by rich plexuses of sympathetic nerves, through the 
influence of which and its special nerve, the pueumogastric, it is in 
intimate relation with every organ of the body. 

The Symptomatology. The local symptoms of disease of the stomach 
are dependent upon : (1) The morbid process which affects it; (2) the 
effect of the process upon the anatomical structure of the organ (atro- 
phy, dilatation, tumor) whereby the size is affected ; (3) the effect upon 
its function. 

The symptoms due (1) to the morbid process are not different from 
the symptoms of similar morbid processes, save that they are modified by 



STOMACH, INTESTINES, AND PERITONEUM. 



481 



the function of the organ or its special anatomy, a canal. Hence con- 
gestions are attended by discharge of mucus; inflammations are attended 
by pain and by a flow of mucus and pus ; ulcers by pain and the acci- 
dents of ulceration (hemorrhage) ; malignant disease by pain and swell- 
ing (tumor), and its accidents, hemorrhage and obstruction ; while to 
each process belong the general phenomena which attend it. But the 
stomach is highly sensitive and resents the intrusion of a process or 
of that which (1) causes or (2) irritates the process. Expression of 
this resentment is shown in the occurrence of hypersesthetic symptoms 
(see the Neuroses), as of pain, in the abolition or derangement of func- 
tion, and in the occurrence of the great pathological reflex act of the 
stomach — vomiting. It will be seen later that this is a symptom of every 
local morbid process of the organ, either directly because of the process 
or on account of the cause of the process, both of which are operative 
in inflammation due to any irritant ; or indirectly because the process 
has set up undue sensitiveness. In the latter instance material, as food 
which the stomach is accustomed to receive, becomes an irritant. 
Abnormal material from morbid processes acts as an irritant, as mucus, 
pus, or blood. 

The morbid processes modify the anatomical structure and lead to 
other morbid conditions, as we see when dilatation succeeds inflamma- 
tion or obstruction of the orifices. Now the symptoms of the secondary 
conditions are the symptoms of such elsewhere — in atrophy, diminution 
in size ; in dilatation, increase in size, with retention and fermentation, 
and finally discharge of contents by vomiting. 

Functional Symptoms. Any local disease of the stomach must influ- 
ence its function ; therefore, conversely, functional symptoms must be 
present in all local diseases. The functions of the stomach are to digest 
and to absorb the products of digestion. The former function is motor 
and chemical, the completeness of which depends upon mixture of the 
food with, and solution in, the gastric juice. The symptoms, there- 
fore, must be due to changes (1) in the motor, (2) in the secretory, and 
(3) in the absorptive function of the organ. 

Central and Reflex Influences. In the consideration of the symp- 
tomatology of gastric diseases the anatomical relations through the 
influence of its vascular and nervous connection must be considered. The 
student is sufficiently familiar with physiology and pathology to know 
that each organ has a representative in the central nerve mass, the 
brain, and that disease in one organ will influence the function and 
create morbid symptoms in another which may happen to be related to 
it through intimate nervous connections. 

The central representative or centre is influential in degree in accord- 
ance with the power and activity of its peripheral adjunct. It is, 
moreover, regulated by higher centres, the psychical, and it in turn 
modifies them. It influences or modifies lower centres, (1) functional, 
(2) vasomotor, (3) motor, or (4) sensory. The result of this mechanism 
is: 1. That functional alteration or organic disease of (a) the gastric 
centre, or (b) of centres of higher control, or (c) of the nerve that connects 
centre and organ, pneumogastric, produces gastric symptoms. 2. That 
gastric diseases produce symptoms in other organs, as palpitation of the 

31 



482 



SPECIAL DIAGNOSIS. 



heart (reflex). 3. That disease of other organs produces gastric symp- 
toms or disease, as the vomiting of pregnancy, or renal calculus, or 
disease of the testicle, or the gastritis of nephritis. Thus, vomiting is 
caused by emotion (high centre) influencing the (lower) pneumogastric 
centre; by a tumor pressiug on or destroying the pneumogastric 
centre; or by a tumor pressing on the pneumogastric nerve, as aneur- 
ism. I have taken the simplest illustration. When we come to the 
study of gastric neuroses the extraordinary influences of the nervous 
mechanism will be appreciated ; or when hysteria is studied, the 
mechanism of its extreme gastric symptoms will be recognized in a 
measure. To continue with vomiting : when its mechanism and 
clinical course is studied it will be found to be due to affections of the 
blood, the poisons of which irritate cerebral centres or nerve plexuses 
in the stomach. 

But gastric diseases also arise because of their vascular connection. 
Thus, in heart disease with venous congestion the gastric veins become 
the seat of congestion with the production of gastric catarrh. Or hepatic 
disease will cause portal congestion and gastric catarrh. 

It is observed, therefore, in unravelling the symptomatology of gastric 
disease, we must first note (A) the subjective symptoms due to (1) pos- 
sible morbid processes, (2) to alterations of function, (3) to alterations 
of size (sense of fulness, etc.). (B) The objective symptoms due to (1) 
morbid processes, (2) to alterations of function, (3) to alterations of 
size. 

Now one of the objective expressions of the morbid process or of 
altered function is seen in changes in the character of the contents of 
the stomach. The contents are obtained for examination when dis- 
charged from the stomach (vomit) or when removed artificially (wash- 
ings). Both fluids are studied by inspection, including microscopical 
examination, by smelling to note the odor, and by chemical and bac- 
teriological examination. Alteration of function is also seen in 
alteration of digestion, and is estimated by chemical and physiological 
methods. The activity of the digestion must be determined by ascer- 
taining the duration of digestion and its degree of completeness, which 
depends upon three factors : (1) The motor power ; (2) the absorptive 
power ; (3) the digestive power of the secretions the activity of which is 
investigated. 

To secure objective data, therefore, the following is necessary : 

I. Physical examination to determine tenderness and the size and 
position of the stomach. 

II. Examination of gastric contents : 

1. Character of secretion. 

2. Amount of secretion. (HC1.) 

3. Determination of the power of digestion of — 

a. Albumin. 

b. Milk. 

c. Starch and sugar. 

4. Determination of the motor power. 

5. Determination of the absorptive power. 

6. Examination of the vomitus. 



STOMACH, INTESTINES, AND PERITONEUM. 



483 



Further Examination. In addition to the examination of the stom- 
ach in order to judge correctly of the nature of gastric lesions as indi- 
cated above, we must ascertain (1) whether the gastric symptoms are 
dependent upon disease of other organs, particularly the eye, nose, aud 
genitalia, the heart aud kindeys, by an examination of each organ, aud 
(2) whether other symptoms are created by gastric disease. 

Toxic Symptoms. There is oue class of symptoms that arise in gas- 
tric disease that are worthy of a few words. They are nervous symp- 
toms due to the absorption of ptomaines or imperfect products of 
assimilation, on account of which, if absorption takes place suddenly 
and in large amounts, coma and couvulsions occur; or, if chronic, 
hypochondriasis, melancholia, mental depression, with vasomotor phe- 
nomena of various kinds, arise. 

Diagnosis from disease of contiguous organs functionally related. 
The student will soon learn that diseases of the stomach which are 
functional in character cannot be differentiated with ease from diseases 
in other organs functionally related. He will find that to draw hard- 
and-fast lines between gastric and intestinal indigestion, or between so- 
called disordered gastric and hepatic function, is impossible. Organs 
which are closely related in physiological function, and which have nerve 
aud blood supply in common, cannot be differentiated when disordered 
function is considered. Hence indigestion and biliousness, or simple 
acute gastritis and duodenitis, are beyond the pale of close discrimina- 
tion. In fact, the symptoms of each blend, in a manner. 

The Data Obtained by Observation. The Objective Symptoms. 

Physical Examination of the Stomach. Inspection. 
Direct inspection of the stomach rarely affords much positive infor- 
mation. When there is much loss of abdominal fat and the stomach is 
well distended, its outlines can sometimes be traced with the eye. The 
best position is behind and above the patient's head while he is lying 
down. If the lower curvature can be traced considerably below the 
navel the stomach is almost certainly dilated, and if, at the same time 
there is a prominent swelling in the pyloric region, accompanied by pro- 
gressive loss of weight and cachexia, the dilatation is probably due to 
cancer of the pylorus. 

Peristaltic waves may be seen with the naked eye, or brought into 
view by the use of the ether spray or faradism. When the pylorus 
is obstructed anti-peristaltic waves may also be seen. The waves of 
muscular contraction begin at the cardiac end or fundus, and extend to 
the pylorus; hence they begin under the ribs of the left side and 
extend downward toward the right lower quadrant. They vary in 
extent with the amount of dilatation. 

An endoscope has been adapted for inspection of the stomach ; but 
such an instrument necessarily can be in the hands of but few, and it 
would be difficult to persuade American patients to permit its use. 

Distention of the stomach with carbonic oxide or air frequently brings 
the outlines of tumors of the pylorus plainly into view, while at the 
same time any tumor lying behind the stomach becomes less distinct, and 



484 



SPECIAL DIAGNOSIS. 



false tumors due to spasm of the gastric muscular coat vanish. Disten- 
tion also helps to map out the whole stomach and to separate it from 
surrounding viscera. 

Palpation. Palpation of the stomach is closely associated with 
auscultation, inasmuch as the former elicits sounds (succussion, gurg- 
ling) which are helpful in diagnosis. (See Auscultation.) 

But palpation elicits information independently of auscultation, 
chiefly in conditions of disease. Epigastric pulsation is common in 
ansernia ; in nervous dyspepsia ; in valvular disease of the heart, particu- 
larly tricuspid regurgitation, producing a liver pulse ; and, more rarely, 
in aneurism of the abdominal aorta. 

Increased resistance may be due to the hypertrophy of the muscular 
coat which coexists with distention of the stomach. When the stomach 
is shrunken and the resistance increased, it may be due to a diffuse car- 
cinoma of the walls of the stomach ; or rarely, to the so-called "fibroid 
stomach," the atrophy and thickening of the walls being due to chronic 
gastritis. 

Increased resistance limited to the pylorus is found in carcinoma. 
The same effect produced by a tense right rectus muscle must be elimi- 
nated. 

Position of Tumor. Cancers of the pylorus are situated usually be- 
tween the xiphoid cartilage and the umbilicus, frequently a little to the 
right of the median line. But they may be found below the umbilicus, 
and exceptionally still lower down. Adhesions to neighboring organs 
commonly prevent the tumor from being moved. 

When it has formed adhesions to the liver or diaphragm it moves 
with respiration. 

From the statistics of Welch, based upon 1300 cases of gastric cancer, 
it appears that a tumor occupies the pyloric region in 60.8 per cent., or 
in three-fifths of all cases, the cardiac orifice being the next most fre- 
quent seat (11.4 per cent.); while in 80 per cent, of all cases a tumor is 
present. As a rule, tumors due to gastric cancer are small, hard, and 
irregular, and gradually increase in size. 

Other non-malignant tumors are occasionally found, and also tumors 
due to adhesions around old ulcers and to puckered scars. The latter 
are distinguished from cancerous tumors not by the sense of touch but 
by their duration and clinical history. 

The most exact method of determining the position and size of the 
stomach is by internal exploration combined with external palpation. 
A bougie is introduced into the stomach and swept over its entire inter- 
nal surface, the position of the bougie being followed from point to 
point by the palpating hand. 

This method is not advisable when it is possible to make a diagnosis 
without it, and is contra-indicated, according to Boas, by the following 
general diseases : Heart disease with failing compensation; angina pec- 
toris; aneurisms of large vessels; recent hemorrhages of whatever kind; 
phthisis in progressive stage; emphysema with bronchial catarrh in 
progressive stage; apoplexies, complete or incomplete; hyperemias of 
the brain ; pregnancy ; continued or remittent fever ; great cachexia. 

It is also contra-indicated by the following diseases of the stomach : 



STOMACH, INTESTINES, AND PERITONEI! M. 



485 



Ulcer with antecedent hsematemesis or black stools; dilatation of stom- 
ach with typical vomiting ; palpable cancer of pylorus, with emaciation, 
coffee-ground vomit and the other classical symptoms of cancer ; in 
mauy neuroses of the stomach in which the character of the disease 
from the rest of the symptoms is clear ; in acute gastric or intestinal 
catarrh associated with fever; when the mucous membrane of the 
stomach bleeds easily. Slight capillary hemorrhages constitute no 
contra-indication. 

It will be seen from the above list that the method has a limited 
range of applicability. 

Pain and Tenderness. Tenderness is elicited by palpation in gas- 
tritis, in dyspepsia, especially the catarrhal form, in ulcer, and in cancer. 
In gastritis and dyspepsia the tenderness is usually diffuse and is not 
constant ; in cancer the tenderness is usually limited to the seat of 
tumor, but is not so marked nor so sharply localized as in ulcer. In 
ulcer tenderness is rarely absent, even when there is no pain, is very 
decided, and is so localized sometimes that it can be covered with the tip 
of a linger. Pain in the stomach from ulcer is chronic, circumscribed, 
and variously described as burning and wound-like. It is aggravated 
by palpation and food or drink, especially hot stimulating drinks, and 
relieved by cold, soothing drinks. It is accompanied frequently by pain 
in the corresponding vertebrae. 

Diffuse pain is met with in acute and chronic gastritis, and in cancer 
of the stomach walls. 

Percussion. Position of the Stomach. The stomach does not occupy 
a fixed position, and is a distensible organ. It is depressed by down- 
ward pressure of the diaphragm in deep inspiration, by emphysema, 
left pleural effusions, enlargements of the liver and spleen, and tight 
lacing ; and raised by any causes which greatly distend the bowels or 
peritoneal cavity — tympanites, peritoneal effusions, tumors, etc. More- 
over, after food is taken the stomach is distended and its position changed, 
being rotated anteriorly from below, the greater curvature rising and 
looking more forward, while the anterior surface has a more upward 
presentation. 

The cardiac orifice of the stomach is fixed by its passage through the 
diaphragm and by peritoneal attachments which it receives there. It 
is behind the sternal insertion of the left seventh rib. The pylorus, on 
the contrary, is freely movable when the stomach is empty ; it is nearly 
in the median line, but when the stomach is full it is pushed several 
inches to the right ; it lies between the right sternal and parasternal 
lines on a level with the tip of the xiphoid cartilage. 

Obrastzow (Deut. Arch, fur Hin. Medicin, Bd. xliii., 5, 417-456) 
divides the space between the navel and the xiphoid cartilage into 
three equal parts, and says that the lower border of the stomach, both 
in men and in women, is in the lower supra-umbilical third. 

In children under fifteen the lower border rarely extends to the 
umbilical line ; after fifty, on the contrary, it often extends below the 
navel. In conditions of bad nutrition it falls nearly to the navel. 

According to Pacanowski and Wagner the upper border of the 
stomach, in the left parasternal line, lies at the lower border of the fifth 



486 



SPECIAL DIAGNOSIS. 



rib or in the fifth intercostal space, rarely at the fourth rib or in the 
sixth intercostal space. In the left nipple line it lies from the fifth 
interspace to the sixth rib, occasionally in the fourth interspace or at 
the seventh rib. In the anterior axillary line it lies at the lower border 
of the seventh or eighth rib, rarely above the sixth rib, never under 
the eighth rib. 

A part of the anterior portion of the stomach and its lower border 
can be determined by percussion. Ordinarily, the most suitable posi- 
tion for examining the stomach is the recumbent one, with the knees 
drawn up so as to relax the abdominal muscles. 

The stomach contains air at all times, but the amount varies greatly. 
The percussion note is tympanitic, frequently with a metallic ring ; its 
quality is peculiar — " stomach tympany." 

The percussion area of the stomach is increased, first, by causes 
external to the stomach ; contraction of the liver, old pleurisy with 
retraction of lung, emphysema, former pregnancies, bad nutrition, and 
tumors pulling down the stomach ; second, by intrinsic causes; disten- 
tion or dilatation of the stomach. 

Conversely, the percussion area is diminished by causes external to 
the stomach ; enlargement of the liver and spleen, left-sided pleural 
effusion, pneumothorax, and hypertrophy of the heart. 

Actual diminution in size of the stomach itself is difficult to demon- 
strate clinically with certainty. If upon inflation the great curvature 
remains at a higher level than 3 to 5 cm. above the umbilicus, diminu- 
tion in size is highly probable. But even then the lower border may 
be prevented from descending by adhesions to surrounding viscera. 

Enlargement of the stomach is generally due to dilatation, and is best 
marked clinically by a low position of the greater curvature. Dilatation 
of the stomach, according to Boas, can be separated from descent of the 
organ only when the greater curvature is more or less below the level 
of the navel, and when the greatest height of the stomach exceeds 
10-14 cm. (4 to 5 J inches). But descent and dilatation are frequently 
present together. 

In order to separate stomach tympany from that of the colon, which 
resembles it, the stomach may be distended with gas, while the colon 
contains solid or liquid matter ; or if the colon be filled with gas the 
patient may be allowed to stand and to drink a glass or two of water. 
In either case the contrast between a dull and a clear note marks the 
boundary between stomach and colon. 

Ziemssen recommends carbonic acid (developed by mixing sodium 
bicarbonate and tartaric acid) to distend the stomach ; the quantity em- 
ployed for adult men is seven grammes of bicarbonate of soda and six 
grammes (one and one-half drachms) of tartaric acid. Adult women 
should receive one gramme less of each. 

As carbonic acid sometimes causes an uncomfortable oppression 
ordinary air is preferred by some. It can be forced in by a hand-bulb 
syringe attached to an ordiuary stomach-tube. The percussion note 
over tumors of the pylorus is imperfectly tympanitic. Welch describes 
it as "tympanitic dulness." Less frequently it is dull, and rarely it 
is flat. 



STOMACH, INTESTINES, AND PERITONEUM. 487 



Traube has called special attention to the left lower portion of the 
thorax which projects over the stomach, " the halfraoon-shaped space." 
In health it gives a tympanitic note, unless the stomach or transverse 
colon is full or the omentum very fatty. In left pleural effusion it is 
dull. (See Diseases of Lungs.) 

Auscultation. Auscultation can determine whether or not there 
is obstruction at the cardia. On listening over the oesophagus with the 
stethoscope when the patient is swallowing a liquid, a spurting sound 
is heard, followed in from five to ten or twelve seconds by a second sound 
which marks the escape of the fluid from the cardiac orifice of the 
oesophagus into the stomach. When there is obstruction of the cardiac 
orifice the second sound may be delayed as long as a minute. 

When the stomach is partly filled with fluid a succussion or splash- 
ing sound can be produced by moving the patient quickly from side 
to side, or by quickly compressing the stomach and allowing it to re- 
bound again immediately. Such sounds are abnormal if they are heard 
long after digestion should be completed and the stomach empty. The 
ear need not be applied to the body, but kept near by while the move- 
ments are made. 

Normally, after drinking fluids a splashing sound is not developed 
lower than the umbilical line. If it is heard below this it is an indi- 
cation of dilatation or of deep positiou of the whole stomach. Dilatation 
is very probable if the splashing sound is heard below the navel in a 
fasting stomach. 

Furthermore, this sound is a sign of atony. If 50 to 100 grammes of 
water be swallowed, no splashing sound is heard unless there is atony 
of the stomach walls; but, if the atony is pronounced, a smaller quan- 
tity will be sufficient to develop the sound. 

Examination of the Stomach by Chemical Methods. These 
methods have for their object the determination of the absorptive, motor 
and digestive energy of the stomach ; the character of its secretions and 
their quantity; and indirectly to supply information bearing upon the 
presence or absence of atrophy, dilatation, and tumors. 

Mode of Procedure. 1. Administer a test breakfast, as advised by 
Ewald (see page 491). 2. Remove the contents of the stomach one hour 
after breakfast is taken, by aspiration or by expression. Aspiration 
consists in the withdrawal of the stomach contents by suction, either 
with the ordinary stomach pump ; by means of a bottle exhausted of 
air, as employed for paracentesis, and connected with the stomach sound ; 
or by connecting the sound with a hand-ball aspirator. 

Expression consists in introducing a sound and assisting the outflow 
of the fluid by pressing upon the epigastrium. If the tube is long 
enough it can be bent so as to assist expression with siphonage. 

Aspiration is less disagreeable to the patient, and is necessary when 
the stomach contents are not fluid enough to flow easily, but it is subject 
to much the same contra-indications as obtain in the case of exploration 
of the oesophagus and stomach (see page 484). 

Expression is not to be employed when there are old ulcers, ulcer- 
ating carcinoma, phthisis with antecedent haemoptysis, or a disposition to 
menorrhagia. 



488 



SPECIAL DIAGNOSIS. 



These methods supply the most reliable information of the condition 
of the stomach and its secretions ; because, when once withdrawn, their 
character can be ascertained accurately and the quantity measured ; and, 
moreover, being able to choose the time of examination, we can decide 
whether or not what is found corresponds with health, and if not, in 
what particular it indicates disease. They permit a diagnosis to be 
made before other methods supply sufficient data. 

A soft rubber tube, with two good- sized openings near its distal ex- 
tremity, should be selected. Stockton suggests a tracing of rings 
around the tube one inch apart, beginning twenty inches from and end- 
ing thirty inches from the lower extremity. By means of the rings the 
length of tube inserted can be told. In healthy adults the distance 
from the incisor teeth to the lower border of the stomach is about 
twenty-two inches. In dilatation it may extend from twenty-four to 
thirty. The distance is partly determined by success in the siphonage. 
If the return flow of fluid does not take place, it is well to either with- 
draw the tube or push it further on, for if too long it may curve above 
the level of the fluid, or if too short it may not reach the fluid. 

After the tube is oiled, or coated with the white of egg, the patient 
should be seated, and the tube at once passed to the back of the 
pharynx, and, with or without guiding by the fiuger, pushed toward 
the oesophagus. It is at once grasped by the oesophagus or lower 
pharynx, and if the patient is instructed to swallow and to breathe 
slowly it is rapidly carried downward by deglutition. Mucus that 
accumulates in the mouth after the tube is passed should be allowed to 
dribble outward, and not be swallowed. It is often of advantage to 
assure the patient by having him pronounce the letter "a" or some 
small syllable. It is not necessary to extend the head backward. 

If a hard tube is used, it must be guided by the operator, who should 
stand back of the patient supporting the head, which has been thrown 
backward. The tube can be passed if the operator is seated in front 
of the patient. This kind of tube is used with the stomach pump. 

Characters of Normal Gastric Contents. The amount of fluid, after 
digestion of the test breakfast has continued for one hour, is from 30 
to 40 c.c. After filtering, the filtrate is clear, yellow or yellowish-brown 
in color. If the digestion is normal, the fluid should contain free hydro- 
chloric acid, and no lactic acid. It should also contain pepsin, rennet 
(the milk-curdling ferment) and organic acids. Albuminoids should be 
converted into peptones, and starches into achroodextrin, dextrose, or 
maltose. 

Chemical and Physical Examination. The following steps 
are necessary, and a description of them will be given in due course. 
1. The acidity is determined by litmus paper. 2. The odor. 3. In- 
spection is employed (q. v.). 4. The presence of free acid, of HC1, 
of lactic acid, of acetic acid, aud of butyric acid are determined. The 
amount of total acidity is then estimated in order to judge of the 
amount of secretiou of the gastric juice or hydrochloric acid. 5. 
Tests are then made to determine the presence of pepsin and pepsin- 
ogen, bearing in mind that if hydrochloric acid is present in a free 
state these constituents are sure to be present. 6. The test for the milk- 



STOMACH, INTESTINES, AND PERITONEUM. 489 

curdling ferment is also made. 7. Having determined the chemical 
nature of the filtrate, examination should be made to determine the 
degree of progress of the digestion of the proteid and the carbohydrate 
elements of the food by testing for proteids, as serum-albumin and pep- 
tone, and by testing for starch and its products. It is to be observed 
that perfect familiarity with normal digestion, and particularly the 
proper length of time required to perform definite acts, is very essential. 

Reaction. The reaction of the contents of the stomach is usually 
acid, from the hydrochloric acid of the gastric juice. It may be alka- 
line in cases of hemorrhages, or in the vomiting known as water-brash. 

Odor. The odor is sour normally, but it may be aromatic from the 
presence of the fatty acids, faecal in obstruction of the bowels with 
faecal vomiting, and, finally, may indicate the nature of poisonous ingesta 
— ammonia, phosphorus, carbolic acid. 

Inspection of the Stomach Contents. The contents of the 
stomach may be obtained by emesis or by aspiration. The latter is 
preferable. They should be inspected, first, as to quantity. If a person 
has taken no food or drink between the evening meal and the following 
morning the stomach should not contain more than three and one-half 
fluid ounces ; more than this is abnormal. The character of the stomach 
contents is important. If undigested food is found after digestion 
normally should be completed, then there is deficient digestive energy. 
No undigested food should be found longer than six or seven hours 
after an ordinary meal of mixed foods, and the stomach should be 
empty much sooner if only starches are taken, as in Ewald's test break- 
fast. 

Mucus is found in small quantity normally, but is increased in 
catarrhal affections of the mouth, throat, or stomach. When its source 
is the mouth, saliva also is generally present. 

Bile and intestinal juice may be regurgitated into the stomach as the 
result of violent emesis, or when the pylorus is much relaxed, or in 
stenosis of the duodenum below the common duct ; bile is then present 
in large quantity if the stomach is dilated. 1 Bile is recognized by the 
usual tests (see under Examination of Urine), and intestinal juice by its 
peculiar properties and the presence of leucin and tyrosin. 

Blood is found in ulcer; cancer; acute, especially toxic, gastritis; in- 
juries to the mucous membrane from the use of the sound for expression, 
and violent retching. It is also common in cirrhosis of the liver, and 
may occur in purpura, peliosis rheumatica, the hemorrhagic diathesis, 
and in yellow fever. 

If the blood is unaltered it can be distinguished from all other sub- 
stances by microscopic examination. Occasionally the blood has the 
appearance of coffee-grounds. The hcemin test serves to distinguish it. 
The suspected material is filtered and a little of the filtrate evaporated 
in a watch-glass; when dry a small portion is mixed with finely pul- 
verized salt upon a glass slip ; it is then covered with a cover-glass and 
one or two drops of glacial acetic acid allowed to flow under the cover- 
glass. The acetic acid is evaporated by slowly heating the slip over a 



i Hochhaus: Berlin, klin. Woch., No. 17, 1891. 



490 



SPECIAL DIAGNOSIS. 



small flame, and when dry a few drops of water are allowed to flow 
under the cover-glass to dissolve the salt. If the vomit contained 
blood, brown rhombic crystals of hsemin (hydrochl orate of hsemin) will 
appear under the microscope. As they are very small, a magnification 
of about 300 diameters will be necessary to bring them into easy view. 

Pus is rarely present in sufficient quantity to be detected by the 
naked eye, but it sometimes occurs in phlegmonous gastritis and when 
an abscess has ruptured into the stomach. In microscopic amounts it 
may be found in severe catarrhal affections. 

Fcecal matter is vomited in complete obstruction of the bowels, and, 
according to Vierordt, in severe diffuse peritonitis. It is recognized 
partly by its appearance and partly by its odor. 

Worms are sometimes vomited ; the round worms not so very unfre- 
qnently ; oxyurides and ankylostomata rarely. 

Digestive Energy. Inspection of the vomited matters, or the contents 
of the stomach removed by aspiration, shows whether there has been 
digestion or not, aud what variety of food, albuminoids or hydro- 
carbons, has been undigested. Boas states that an abnormally great 
quantity of solid matter and small amount of chyme indicates an ab- 
normal retention of the latter, which is usually brought about by motor 
weakness (atony, dilatation of the stomach), or dilatation in conjunction 
with deficient absorptive power. Not rarely when there is a large 
residue in the stomach the contents separate into three layers. The 
uppermost is mucus or undigested food ; the second, generally the 
thickest layer, consists of fluid ; and the lowest layer is chyme. Such 
a formation, he says, points to abnormally long retention as the result 
of stenosis and consecutive dilatation, or to motor weakness. 

One hour after the administration of a test breakfast of 35 grammes 
of white bread and 300 grammes of water there should remain 
40 c.c. Hence if, after such a breakfast, there is found a much greater 
quantity, then motor or absorptive insufficiency may be considered 
to exist. A filtrate of 100 to 300 c.c. is very probably due to organic 
obstruction to the outflow, stenosis of the pylorus, adhesions, or dis- 
location of the pylorus. Of course, to be sure that the stomach contains 
nothing at the time of giving the breakfast, it must first be emptied. 

When the stomach has retained its contents a long time, as in dilata- 
tion, so that fermentation has taken place, sarciua? and torulse may be 
found. 

Tests for the Presence of Acids. Normally lactic acid is 
found during the first half-hour of digestion, when starches have been 
taken. When only meats have been taken lactic acid is not found. 
The secretion of hydrochloric acid is not delayed until then, but is at 
first combined, and cannot be detected as free acid until half or three- 
quarters of an hour afterward. The stomach contents, when aspirated 
or expressed, should be filtered before testing. 

Free acids. The most sensitive test for free acids is Congo red. 
Filter paper soaked in it and allowed to dry is turned a light greenish- 
blue by HC1, and a darker blue by lactic acid. Wolff 1 was able to 

1 Trans. Phila. Co. Med. Soc, 1889, x. 305. 



STOMACH, INTESTINES, AND PERITONEUM. 



491 



detect one part of HC1 in 20,000 parts of water. When no reaction 
is obtained, therefore, entire absence of acidity may be assumed. 

Free HCl. Tropceolin 00 is declared by Boas to be an absolutely cer- 
tain test for HCl. A saturated alcoholic solution is of an orauge-yellow 
color. Three or four drops of it are placed in a white porcelain dish and 
spread upon the sides of the dish by rotating it. The same amount of 
the fluid to be tested is then allowed to trickle down the sides of the dish 
and to be intimately mixed with the tropseolin. Upon heating the dish 
over a small flame, splendid lilac-blue to blue streaks, characteristic of 
HCl, will appear if that acid is present. No organic acid gives the 
same color. 

Tropseolin paper is turned brown by gastrice juice containing HCl, 
the brown changing to blue upon the paper being heated. Organic 
acids give a brown color also, but it disappears upou heating. 

Phloroglucin vanillin, introduced by Giinsburg, is also a very sensitive 
test for HCl. The following combination is said by Boas to be more 
sensitive than the ordinary one, which contains only 30 grammes of 
absolute alcohol : 

Phloroglucin 2.0 (gr. xxx) 

Vanillin 1.0 (gr. xv) 

Alcohol (80 per cent.) 100.0 (f^iij) 

Three drops are put into a porcelain dish and an equal quantity of 
the stomach filtrate. Upon cautious heating over a small flame a beau- 
tiful carmine surface is formed, especially at the edges. The same color 
is not produced by organic acids. Filter paper soaked in it and mois- 
tened with a few drops of stomach filtrate, containing HCl, changes on 
heating to a beautiful carmine, which is unaltered upon the addition of 
ether. 

Test for Free HCl. Boas' method is a modification of that of Mintz. 
Ten c.c. of the gastric fluid are shaken with 100 c.c. of ether until 
organic acids are removed. The Congo-red test is then employed until 
the grayish-blue discoloration cannot be secured. 

In testing for the presence of HCl, it is better to give the patient a 
meal which is known to be digestible within a certain time by stomachs 
in a normal state, otherwise HCl may appear to be absent because it is 
still combined with albuminoids. 

Ewald's test breakfast is the simplest. He gives in the morning, on 
an empty stomach, one or two ounces of bread and a cup of tea or an 
equivalent amount of water. In one hour the contents of the stomach 
may be aspirated and tested for HCl. 

Amount of Free HCl. If by previous tests HCl is found alone, its 
percentage is easily calculated. To a measured quantity of the gastric 
fluid add drop by drop from a burette deci- normal alkaline solution 
until the acid is neutralized. One c.c. of the alkaline solution is 
equivalent to 0.003646 HCl. Multiply the number of c.c. required to 
neutralize 10 c.c. of the gastric solution by 0.003646, and again by 10, 
the result will be the percentage of acidity. If 6 c.c. are used the 
percentage will be 6 X 0.003646 X 10 = 0.218, within the normal range, 
or from 0.14 to 0.24 per cent. Giinsburg's test can be used to estimate 



492 



SPECIAL DIAGNOSIS. 



the quantity of HC1. This is employed by diluting the stomach con- 
tents until the test is not responded to. In health the limit of response 
is found when one part of HC1 is found in 20,000 parts of the fluid. 
In abnormal conditions, when the gastric fluid is diluted, one-half the 
proportion is 2 to 20,000, or 1 in 10,000. If the fluid is diluted to 10 
times its original strength, it is 10 to 20,000, or 1 in 2000. 

Significance of HCl. If abseut one to three hours after taking milk 
or nitrogenous food, there is serious impairment of function. An 
increase to 0.33 per cent, does not imply functional disorder. Absence 
occurs in cancer and chronic gastritis ; an increase in ulcer or in 
neuroses. 

Presence of Lactic Acid. If this continues an hour after the test 
meal it is pathological. Its presence may be determined by Uffelmann's 
reagent : Mix one drop of pure carbolic acid with five drops of a 
dilute solution of neutral ferric chloride. Add sufficient water to 
render the whole of an amethyst-blue color. In this add a few drops 
of the gastric fluid. A mere trace of lactic acid will change the blue 
to a light yellow. 

The test for lactic acid is simulated when phosphates, glucose or 
alcohol is present in the gastric juice. The lactic acid should be 
removed by extracting with ether. 

The Fatty Acids. Butyric acid is detected by the same reagent. It 
strikes a tawny yellow color with a reddish tinge. As much as one 
part of the reagent in 2000 is required. 

A few c.c. of the filtered gastric fluid is shaken with three or four 
times the amount of ether. The ether is poured off when it rises on 
the top, and fresh ether added and the washing repeated. After the 
third washing the ether that cannot be poured off is evaporated through 
a water bath. Add a few drops of water to the residue and then an 
equal quantity of the reagent. The characteristic color is produced. 

The Total Acidity. This is determined by titratiou. Fill a Mohr's 
burette with a deci-normal solution of caustic soda. To 10 c.c. of the 
filtered gastric fluid add two drops of an alcoholic solution of phenol- 
phthalein. Allow the caustic soda solution to drop slowly from the 
burette into the fluid, until the red color which is produced does not 
disappear on shaking. The color is produced by the action of the 
alkali on the phenol-phthalein. Four to six c.c. of the caustic soda 
solution are required to neutralize the acid in normal digestion. The 
degree of acidity is expressed in percentage. Thus if four c.c. neutralize 
ten c.c. the total acidity will amount to 40 per cent., or if six c.c. are 
required, to 60 per cent, of the normal. 

If more or less than the amount just indicated of the alkaline 
solution is required to neutralize the acid, the total acidity is increased 
or diminished, and hence is abnormal. 

Test for Fatty Acids. In addition to Uffelmann's test the fatty acids 
may be detected by boiling a few c.c. in a test-tube over the mouth of 
which blue litmus paper is attached. If acid is present its vapor will 
change the blue to red. Particles of pure fat may be seen floating in 
the gastric contents, or they may be extracted by ether. Acetic acid 
is recognized by its odor, particularly after heating the solution. It 



STOMACH, INTESTINES, AND PERITONEUM. 



493 



may be detected as follows : Secure an ethereal extract of the gastric 
contents, evaporate in a water bath, and dissolve the residue in water. 
Neutralize the watery solution with sodium carbonate, and then add 
neutral ferric chloride solution. A blood-red color results if acetic acid 
is present. 

Alcohol is detected by its odor, and by Lieben's iodoform test. 
Distil the stomach contents, add to a portion a small quantity of liquor 
potassa, and then a few drops of iodine-iodide of potassium solution. 
A precipitate of iodoform takes place slowly if alcohol is present. If 
acetone is present it forms rapidly. 

Test for Pepsin. If HC1 is present add 5 c.c. of a gastric filtrate to 
a small piece of egg-albumin. Allow digestion to take place for several 
hours at 37° to 40° C. Non-digestion indicates absence of pepsin. 

If HQ is absent pepsinogen is found alone. Add two drops of a 25 
per cent, HC1 solution to 10 c.c. of the gastric contents. Add to this 
solution a small portion of egg-albumin. If it is dissolved, pepsinogen 
was converted into pepsin by HC1. 

Test for Rennet (the milk-curdling ferment). This may be detected 
as follows : From 5 to 10 c.c. of cow's milk of neutral reaction is boiled 
and added to neutralized and filtered gastric juice. Place the mixture 
on a warm bath heated to 30° to 40° C. The casein of the milk is 
precipitated in flakes in from 20 to 30 minutes if the ferment is present. 

Test for Carbohydrates. Add a few drops of Lugol's solution to the 
gastric contents. If starch is present it turns blue. If erythrodextrin, 
it becomes purple. If the digestion has proceeded so far as to change 
starch into dextrose, the iodine hue remains unchanged. The starches 
should be completely digested an hour after they are taken into the 
stomach, hence in health the iodine hue should not change after this time. 

Test for Peptones. If the albumin has been converted into peptone 
a distinct purplish-red color is struck when a small amount of caustic 
potash and a little dilute cupric sulphate are added together. If there 
is albumin or syntonin the color is violet blue. 

Gunsburg's Test of Digestive Energy. Giinsburg has intro- 
duced the use of iodide of potassium in the following way : From three 
to five grains are placed in a rubber tube of extremely thin walls; the 
ends of the tube are then bent and brought into apposition and fastened 
in that position with three fibrin threads made firm by preservation in 
alcohol. The whole packet is then pressed into an empty gelatin cap- 
sule and given to a patient to swallow one-half hour after a test break- 
fast. The saliva is tested for iodine every fifteen minutes. The more 
rapid the solution of the capsule and fibrin threads, the sooner the iodine 
can be absorbed and appear in the saliva, and hence this rapidity is an 
index of the digestive energy. 

The method is liable to fallacies: solution of the fibrin may take 
place in the intestine instead of the bowel, and the threads may be 
loosened by the acids of fermentation instead of by digestion. Never- 
theless the test is a valuable one, especially when aspiration is inad- 
missible. 

Test of the Absorptive Energy of the Stomach. Pen- 
.zoldt aud Faber recommend the administration of three grains of chemi- 



494 



SPECIAL DIAGNOSIS. 



cally pure iodide of potash, i. e., free from iodic acid, a short time 
before dinner. Any fragments of free iodine adhering to the iodide of 
potash are first carefully washed away. The saliva is tested for iodine 
with starch-paper and fuming nitric acid. If absorption is active a 
violet color is obtained in from six and one-half to eleven minutes, and 
a blue color in from seven and one-half to fifteen minutes. The char- 
acter of the food taken is said to have considerable influence in retard- 
ing the appearance of the reaction, so that the blue reaction may not 
appear for forty-five minutes. 

Boas states that in dilatation of the stomach the reaction may be 
delayed to two hours, and in cancer as long as eighty-two minutes. 

Test of the Motoe Power. Ewald and Sievers have suggested 
the use of salol ; fifteen grains are given, and normally salicylic acid 
should be detected in the urine in from forty to sixty minutes, or in 
seventy- five minutes at the latest. If it is deferred still longer, motor 
insufficiency is indicated. Urine containing salicylic acid gives a dark, 
brownish-red color upon the addition of a drop of tincture of the chloride 
of iron. 

Microscopical Appearance of Vomit. The illustration from 
Von Jaksch shows the various matters which may be found in vomited 



Fig. 79. 




Collective view of vomited matter. (Eye-piece III., objective 8 A, Reichert.) 
a, Muscle fibres. 6, White blood-corpuscles, c, C, Squamous epithelium, c", Columnar 
epithelium, d, Starch grains, mostly already changed by the action of the digestive juices. 
e, Fat globules'. /, Sarcinse ventriculi. g, Yeast fungi, h, Forms resembling the comma bacilius, 
found by the author once in the vomit of intestinal obstruction, i. Various micro-organisms, such 
as bacilli and micrococci, fc, Fat-needles ; between them connective tissue derived from the food. 
I, Vegetable cells. (Von Jaksch.) 

matter. Briefly, they are columnar and squamous epithelium ; white 
blood-corpuscles acted on by gastric juice ; red blood-corpuscles. The 
corpuscles are usually isolated. The red are rarely perfect, and in the 
white little more than the nuclei remains. From the food we may 
also find muscle fibres, fatty globules and fat-needles, elastic fibres and 



STOMACH, INTESTINES, AND PERITONEUM. 495 



connective tissue, starch granules, and vegetable cells. Muscle fibres 
are recognized by their transverse striation. Fat globules are soluble 
in ether, and are recognized by their refracting powers. Starch 
granules stain blue, with iodo-potassic-iodide solution. 

In addition, fungi of many forms are found, as the mould fungi ; 
the yeasts, and fission fungi. The latter are recognized after staining 
by the iodo-potassic-iodide solution, which colors them blue. The most 
important fission fungi are the sarcinse ventriculi. They are of a dark 
gray tint, stain mahogany-brown to reddish brown with the above- 
mentioned solution, and resemble in shape bales of wool. (See Bacterio- 
logical Diagnosis.) 

Gastric Hemorrhage. Hemorrhage of the stomach, hcematemem y 
or vomiting of blood, is due to an organic lesion, or the effects of acute 
irritant poisoning. The blood is vomited. Care must be taken to see 
that the vomited blood is not from the upper air-passages, and pre- 
viously swallowed. If the hemorrhage is profuse, the blood may cause 
irritation of the larynx, and provoke paroxysms of coughing. It is 
often difficult, therefore, to distinguish hemorrhage from the lungs and 
hemorrhage from the stomach. 



HiEMATEMESIS. 

1. Previous history points to gastric, hepatic, 
or splenic disease. 

2. The blood is brought up by vomiting, prior 
to which the patient may experience a feeling 
of giddiness or faintness. 

3. The blood is usually clotted, mixed with 
particles of food, and has an acid reaction. It 
may be dark, grumous, and fluid. 

4. Subsequent to the attack the patient passes 
tarry stools, and signs of disease of the abdomi- 
nal viscera may be detected. 



HEMOPTYSIS. 

1. Cough or signs of some pulmonary or car- 
diac disease precedes, in many cases, the hemor- 
rhage. 

2. The blood is coughed up, and is usually 
preceded by a sensation of tickling in the throat. 
If vomiting occurs, it follows the coughing. 

3. The blood is frothy, bright red in color, al- 
kaline in reaction. If clotted, is rarely in such 
large coagula, and muco-pus may be mixed with 
it. 

4. The cough persists, physical signs of local 
disease in the chest may usually be detected, 
and the sputa may be blood-stained for many 
days. (Osler.) 



The hemorrhage may continue within the stomach without exciting 
vomiting. The general symptoms of hemorrhage may appear first, as 
pallor, dimness of vision, giddiness or fainting. The blood which 
comes from the stomach is usually acted upon by the gastric juice, and is 
dark, clotted, and partially digested. It is often mixed with food. It 
is acid in reaction. In large hemorrhages the blood may be fluid, and 
of a scarlet color, but if retained for any length of time is coagulated. 
The vomited matter has the appearance of coffee-grounds, when there 
is a small amount of blood. When large in amount, and digested, it 
appears like tar. 

Vomiting is usually followed by movements of the bowels. The mat- 
ter discharged is of characteristic appearance. It is black or tarry. It 
is distinguished from hemorrhage of the intestinal canal below the 
duodenum by the color of the blood. In intestinal hemorrhage from 
this situation, the blood is distinctly red. The dark stools must not be 
confounded with the same character of stools seen when iron or bis- 
muth is taken. In rare instances a hemorrhage of the stomach may 
take place because of disease of the lower part of the oesophagus. 

Causes. 1. General diseases from changes in the blood cause gastric 
hemorrhage, as scurvy, purpura, hemorrhagic smallpox, yellow fever, 



496 



SPECIAL DIAGNOSIS. 



acute yellow atrophy of the liver, and in severe anaemia, leukaemia, 
Hodgkin's disease, aud pernicious anaemia. 2. Ulcer of the stomach. 
3. Cancer of the stomach. 4. Ulcer of the duodenum. 5. Portal con- 
gestion, as in cirrhosis of the liver, and other forms of chronic hepatic 
disease ; disease of the spleen. 6. Congestiou due to disease of the 
heart. 7. In chonic Bright's disease with atheroma. 8. Rupture in 
aneurism. 9. Vicarious menstruation. 

Profuse and sudden hemorrhage, in the absence of well-marked 
symptoms of disease, is in nearly all cases due, either to latent ulcer, 
or to congestion of the stomach from early cirrhosis of the liver. 

Data Obtained by Inquiry. The Subjective Symptoms of 
Diseases of the Stomach. 

The patient suffering from gastric disorder will be likely to complain 
of one or more of the following symptoms : Disorder of the appetite, 
bad taste in the mouth, thirst, eructations, pyrosis, distress, weight and 
burning after meals, flatulency, nausea, vomiting, constipation, diar- 
rhoea, pain, vertigo, and cardiac palpitation. The subjective symptoms 
are detailed in the section on gastric neuroses. 

Bad taste in the mouth, with a heavy breath, is usually due to acute 
catarrh ; it may be present in chronic catarrh. It is said to be 
characteristic of the acute form of gastritis popularly known as bilious- 
ness. 

Thirst is not a symptom of gastric disorder alone ; it is a symptom 
of diabetes and all conditions in which the body has lost fluids, as water 
by vomiting or purging, blood by hemorrhage, or water by evaporation 
and combustion (fever). It is common in acute and chronic gastritis, 
particularly in the alcoholic form. 

Distress, weight, and burning. They are frequent complaints. They 
exist in varying degrees, and may be single or combined. (See Gastric 
Hyperesthesia.) 

Nausea. This symptom is usually associated with vomiting. In 
some persons it is impossible to excite vomiting, although they may 
suffer intolerably from nausea. Nausea is akin to vomiting in its 
mechanism aud clinical associations (q. v.). It is a common incident in 
chronic interstitial nephritis. In old people, with arterial sclerosis aud 
defective renal elimination, it is common. It may be due to irritating 
ingesta, to hyperacidity, to gastrectasia, or to toxins formed within the 
stomach. 

Vomiting. Vomiting takes place when the stomach is compressed 
by the abdominal muscles and diaphragm, coincidently with relaxation 
of the so-called cardiac sphincter of the oesophagus. Sometimes there 
are nausea and violent efforts at expulsion on the part of the stomach, 
but no vomiting occurs because the cardiac orifice of the stomach is not 
at the same time opened. Again, there may be profound relaxation of 
the oesophagus, but no compression of the stomach by the diaphragm 
and abdominal muscles. Both factors must operate at the same time to 
result in vomiting. This explains why it is that some persons suffer 
extreme nausea and have even violent retching, but are unable to vomit. 



STOMACH, INTESTINES, AND PERITONEUM. 



497 



It is to modern physiologists — Schiff and Budge and Brunton — that 
we owe a correct explanation of the physiology of vomiting. 

From them we learn that there is a nervous centre for vomiting, 
which is seated in the medulla oblongata, in close proximity to and inti- 
mately connected with the respiratory centre. It is to this centre that 
impressions are sent from the brain itself or from various portions of the 
body by their nerve supply, and from this centre that motor impulses 
are transmitted to the muscles concerned in the act of vomiting, and to 
the stomach and oesophagus. In his usual graphic manner, Brunton has 
described the entire mechanism. 

By a very good diagram (see Fig. 80) the author indicates the afferent 
nerves which transmit impulses to the vomiting centre, exciting it to 

Fig. 80. 




action. They are : pharyngeal branches of the glosso-pharyngeal ; pul- 
monary branches of the vagus ; gastric branches of the vagus ; gastric 
branches of the splanchnic ; renal, mesenteric, uterine, ovarian, and 
vesical nerves. Fibres pass downward from the brain, conducting im- 
pressions to the vomiting centre from the organs of special sense, from 
the brain substance or its membranes when the seat of disease, or from 
central ganglia excited by emotion or imagination. 

From this it is seen that vomiting is a reflex act : that its mechanism 
is quite simple ; and that a proper understanding of this mechanism is 
essential to a correct appreciation of its pathology and treatment. Refer- 
ence has not been made to the vomiting that occurs in the initial stage of 

32 



498 



SPECIAL DIAGNOSIS. 



many fevers, and in septicaemia, uraemia and allied affections, and to the 
vomiting of hysteria. In the former it is doubtless due to the direct 
action of the poisoned blood on the centre, but it can also readily be 
seen to be due to the propagation of impulses to the centre from the 
brain that is irritated by the blood. If the phenomena of hysteria are 
due to an abeyance of the processes of inhibition, the occurrence of 
vomiting can be said to arise from the non-control, by higher centres, 
of this centre. (From " Vomiting, Physiological and Clinical," Trans. 
Penna. State Med. Soc. Musser.) 

The significance of vomiting in a given case can sometimes be deter- 
mined very readily, and sometimes it remains in doubt after very careful 
examination and questioning of the patient. In seeking for the explana- 
tion of vomiting it is of importance to find out the previous health of the 
patient ; whether it occurred after the patient had been ill for a longer 
or shorter time, or suddenly, when he was in apparent health, or whether 
it formed one of the initial symptoms of an acute disease. 

Again, inquiry should be made as to the supposed cause of the vomit- 
ing ; whether it was excited by the taking of food, drink, or medicine, 
or by some disgusting sight or odor. 

Further, the time of the occurrence of the vomiting should be ascer- 
tained, as well as its frequency, and whether preceded by nausea, pain 
(noting its locality), injury, coughing, jaundice, or constipation. 

The position of the patient at the time the vomiting occurs some- 
times furnishes a valuable clue to its cause. 

The effect of the vomiting is sometimes of aid in diagnosis. In ulcer 
and migraine, for example, it affords marked relief. 

Finally, the appearance and quantity of the matter vomited is very 
important (see Dilatation). 

Vomiting may occur occasionally, persistently, or periodically. It 
may be projectile and painless, or difficult and painful. The former is 
characteristic of cerebral disease or reflex vomiting ; the latter of local 
gastric disease. 

When vomiting occurs suddenly, without antecedent illness, it usually 
indicates some local affection of the stomach, or is due to some nervous 
impression, or marks the onset of some acute general disease. 

The local affections of the stomach attended by vomiting are acute 
and chronic gastritis (especially the catarrhal form), dyspepsia, ulcer, 
cancer, and dilatation. 

In acute gastritis there will be a history of an acute illness marked 
by decided local and general symptoms. The cause of the gastritis may 
be found to be over-eating of highly seasoned or indigestible food ; abuse 
of alcohol, narcotics, or sedatives ; drinking water to which the patient 
is unaccustomed ; poisoning with such drugs as arsenic and mercury | 
sudden changes in atmospheric conditions in susceptible persons. 

The vomiting is preceded by nausea, gastric pain, and tenderness, and 
often followed by profound prostration. 

The vomited matters consist, first, of the contents of the stomach 
(which may throw light on the cause of the attack), then of mucus, 
saliva (which has been swallowed), bile, and, in grave cases, altered 
blood. 



STOMACH, INTESTINES, AND PERITONEUM. 



499 



In chronic gastritis vomiting often occurs in from half an hour to an 
hour and a half after eating, the food being only partly digested and 
sometimes coated with mucus. It does not produce the prostration that 
vomiting in acute gastritis does, and is followed by some relief to the 
gastric uneasiness and pain. The emaciation may suggest cancer of the 
stomach. 

In ulcer of the stomach vomiting is rarely absent. It occurs usually 
soon after taking food, and its occurrence affords relief to the gastric 
pain. There is nothing characteristic in the vomit unless it contains 
blood. Welch thinks that gastric hemorrhage in recognizable amount 
occurs in about one- third of the cases. 

In cancer of the stomach vomiting is an almost constant symptom, 
but it may not occur until comparatively late in the disease, or, more 
rarely, may be one of the earliest symptoms. Usually it appears first 
after dyspeptic symptoms have persisted for some time. There is no 
uniformity in the frequency of its occurrence or in the character of 
the vomit. As a rule, vomiting occurs at a longer interval after taking 
food than in the case of ulcer, and the ejection of food does not give 
as much relief to the patient. Vomiting may occur every day or 
several times a day in the early stages, but if dilatation of the stomach 
develops, as it usually does in cancer of the pylorus, vomiting may be 
deferred for several days, and then be correspondingly more copious in 
amount. Blood, frequently altered by gastric juice so as to resemble 
coffee-grounds, is a common constituent of the vomit (see under Inspec- 
tion — Vomit). 

Vomiting frequently marks the onset of acute diseases, especially 
pneumonia and the eruptive fevers and yellow fever. Marked vomiting 
generally indicates that the case will be severe. 

Nausea and vomiting are excited in some persons by the sight of 
blood, or by a horrible or loathsome spectacle ; others are more suscep- 
tible to foul odors and disgusting tastes. 

Vomiting is frequently reflex, that is to say, irritation at some point 
is transmitted by the proper afferent nerve to the vomiting centre and 
then reflected to the stomach. Vomiting of this character occurs in 
pregnancy, diseases of the ovaries, uterus, bladder, prostate, lungs, nose, 
eyes, kidneys, intestine, peritoneum, liver, gall-bladder, and bile-ducts. 

Vomiting is found to be of reflex origin when there is no local affec- 
tion of the stomach present, and no general disease to account for it, and 
when a remote source of irritation can be discovered, the removal or 
mitigation of which checks the vomiting. The particular organ which 
is the source of the irritation must be determined by a careful physical 
examination guided by the indications furnished by the age, sex, time of 
occurrence, habits and other symptoms which accompany the vomiting. 

The nausea and vomiting from which many women suffer during the 
early months of pregnancy are most marked on rising in the morning ; 
they are aggravated if the patient has been on her feet much or has been 
subjected to any exhausting or worrying influence ; on the other hand, 
they are relieved by quiet and the recumbent posture. In diseases of 
the ovary, uterus, bladder, and prostate there are local pain, catarrhal 
symptoms, inflammation or enlargement to attract attention. 



500 



SPECIAL DIAGNOSIS. 



The lungs probably are not often the cause of reflex vomiting. 
Rarely, however, phthisis is so masked by gastric symptoms and vomit- 
ing that it may be overlooked. More frequently it is the act of cough- 
ing and the effort to expel the sputa from the throat which produces the 
vomiting. Expectoration tickles the throat and may play the part of 
the finger or feather in inducing vomiting. This seems to be the explana- 
tion of the vomiting which ensues upon a hard spell of coughing in 
pertussis. 

Peritonitis may be suspected to be the cause of vomiting if there has 
been injury to the peritoneum from a surgical operation, or if it has 
been exposed to infection through the uterus and tubes, or from disease 
of organs surrounded by it, as the vermiform appendix. Vomiting may 
be the only symptom present excepting collapse. The fluid is not ejected 
alone, but regurgitated, and may seemingly pour out of the stomach. 
Large amounts of fluid are discharged, clear or of a green color. 

In the vomiting due to the passage of a renal calculus or gall-stone 
the colicky pains and their location definitely point to the source. 

Vomiting is also a marked symptom of diseases in which poisons 
circulate in the blood ; they produce vomiting probably by direct irritation 
of the vomiting centre. Among such diseases are the specific fevers, 
notably scarlet fever and yellow fever ; sewer-gas poisoning ; diseases of 
the liver and kidney, which produce cholwmia and urosmia, particularly 
cirrhosis of the liver and interstitial nephritis. 

The vomiting of uraemia usually occurs in the morning. It is accom- 
panied by nausea and depression. Whenever morning nausea and 
vomiting occur in an adult without obvious local cause the urine should 
be examined. Other confirmatory signs are high-tension pulse, ac- 
centuation of the aortic second sound, and hypertrophy of the heart. 

Vomiting due to cerebral disease is well recognized. In early life it 
is a characteristic feature of meningitis and tumor of the brain. It is 
likewise of moment in later life. I am of the conviction, however, that 
it is not sufficiently recognized as one of the first symptoms of apoplexy. 
True, we find apoplexy occur after a full meal, when the attack is asso- 
ciated with indigestion, with efforts at vomiting. It is not to these cases 
that reference is made, but to cases of painless, often watery vomiting, 
occurring without nausea and without retching. A sudden, violent 
propulsion of the stomach contents, ceaseless, unrelieved by remedial 
measures, has been seen by the writer to precede other signs of apoplexy 
by from thirty minutes to twenty-four hours. In all cases of an apo- 
plectic character the pulse is slow and full, while in nausea and vomiting 
from other causes, in the aged particularly, it is weak and feeble. 
Moreover, some alteration of breathing is noticed. It is either irregular, 
or slow, or unduly hurried. It proves the intimate relation of the 
vomiting and the respiratory centres. Further, strength is seen, not 
weakness; in the apoplectics the face is congested, not pallid, as in 
simple sick stomach. The other peculiarities of cerebral vomiting have 
been indicated. 

Diagnosis. Vomiting is readily recognized. It is often productive 
of serious symptoms. It may cause apoplexy or cerebral congestion ; 
it may cause acute overdistention of a dilated heart, as in aortic regur- 



STOMACH, INTESTINES, AND PERITONEUM. 



501 



gitation. If it continues any length of time and much fluid is ejected 
it is attended by anuria, and rapidly followed by collapse. Thirst is 
also produced. 

Flatulency. Flatulency is caused by an accumulation of gas in 
the stomach or intestines. It is a very common source of complaint on 
the part of patients. Gastric flatulency is marked by a distention of the 
stomach, with the discomfort which it occasions, and by the eructation 
of gas at variable intervals after the taking of food. When the gas is 
the result of fermentation with the production of the fatty acids, flatu- 
lency is frequently accompanied by pain, which is relieved by eructa- 
tions. When the distention is great or long-continued, disturbances in 
the action of the heart, particularly palpitation and intermittency, are 
liable to occur. Occasionally the breathing is interfered with, aud, from 
the apprehension which this symptom and palpitation excite, faintness 
and inaptitude for mental and physical work may arise. 

Excessive flatulency is a common manifestation of hysteria. Such 
patients may complain of something rising into the throat from the 
stomach and smothering them [globus hystericus). There may also be 
tympanites, and even phantom tumor. It may be necessary fully to 
anaesthetize the patient to diagnosticate the latter from genuine tumor. 

Vertigo. The stomach is but one of a number of sources of the 
production of vertigo. Some patients find by experience that certain 
articles of food, such as oysters or lobsters, have to be avoided because 
they produce vertigo, although digestion is good, and more indigestible 
articles can be taken without inducing any such result. 

In other cases acute indigestion from over-eating, particularly if it 
result in the development of an acid condition of the stomach, is apt to 
be accompanied by vertigo when the stomach symptoms are most severe. 
Usually the vertigo is associated with headache, more or less intense; it 
is relieved by closing the eyes and lying down, but does not wholly 
disappear until all the symptoms gradually subside after free vomiting. 
Some persons are subject to so-called " blind " headaches — headaches 
accompanied by dimness of vision, more or less mental confusion and 
uncertainty of gait, possibly with staggering and often with vertigo. 
Such headaches appear to be due to an acid condition of the stomach, and 
are relieved by alkalies or vomiting. 

It is difficult to separate the vertigo of chronic gastric or gastro- 
intestinal dyspepsia from that of lithsemia or latent gout. Probably 
both are due not to any local irritation transmitted to the brain, but to 
the circulation in the blood of toxic products of digestion, which act 
upon the brain. The vertigo is not as severe as in acute indigestion 
or acute dyspepsia, but it is constant. With some patients it is asso- 
ciated with unconquerable timidity of walking alone upon the street. 

Pain. Cardialgia is a form of discomfort in the epigastrium scarcely 
amounting to pain, but attended by heartburn or acidity. Gastrodynia 
is a violent pain spoken of as cramp or spasm of the stomach. The 
pain is transient. Gastralgia is a form of pain with features like that of 
neuralgia, occurring when the stomach is empty. (See Gastric Neuroses.) 

Pain referred to the stomach is situated in the upper zone of the 
abdomen, below the ensiform cartilage, between the ribs of the two sides, 



502 



SPECIAL DIAGNOSIS. 



usually in the median line. It may be along and under the left ribs. 
Pain in this situation may be due to a number of causes. 1. Pain from 
myalgia, neuritis, or neuralgia of the intercostal nerves, which terminate 
in this situation. (See Abdominal Pain.) 2. Localized peritonitis or 
perigastritis, a cause for which may be found in the occurrence of infec- 
tion or injury of the peritoneum from disease of contiguous organs. 3. 
Affections of the pancreas may cause pain. a. Pancreatic colic, a rare 
condition associated with diarrhoea, intestinal dyspepsia, and salivation. 
The pain is paroxysmal, the attacks lasting two or three hours, b. Pain 
due to carcinoma of the pancreas, darting or lancinating in character, 
associated usually with tumor, jaundice, and emaciation, c. Pain due 
to pancreatic hemorrhage. It is sudden and extremely severe, attended 
by collapse. 4. Pain in this situation may be due to aneurism of the 
aorta, or of the coeliac axis. It is constant, and of a boring character, 
and may be associated with pain shooting along the course of the lum- 
bar nerves. The physical signs of aneurism are present. 5. Pain in 
this region may also be due to hepatic colic. 6. It may be due to dis- 
ease of the vertebrae. We should look for the sixth or seventh dorsal 
vertebra to be affected, hence higher up posteriorly than the area affected 
in front would indicate. Finally, 7. Affections of the stomach. Of 
these w r e have : a. Gastralgia in all its forms. (See Gastric Neuroses.) 
b. Acute and chronic gastritis, c. Gastric ulcer, d. Carcinoma of the 
stomach. To the first class belongs a peculiar pain which occurs in 
locomotor ataxia, which on account of its sudden onset, with alarming 
vomiting, and its frequent repetition, is known as a gastric crisis. 

In diseases of the stomach pain is a very common symptom. It is of 
all degrees, from a mere sense of discomfort or uneasiness to agony. 
In atonic dyspepsia there may be no local gastric symptoms except a 
feeling of weight and fulness. In nervous dyspepsia there is usually 
uneasiness or discomfort after eating, and in gastralgia the pain is 
characteristic. It usually comes on while the stomach is empty, and fre- 
quently recurs daily at the same hour. At first the pain is slight and 
easily borne, but it gradually increases in severity. It is common for 
the pain after once reaching its height to subside, and then recur in the 
same way. Each succeeding paroxysm is worse than the preceding 
one, until a climax of agony is reached. In character the pain is 
gnawing and cramp-like, doubling the patient up, and after subsiding, 
leaving him moist with cold sweat and in partial collapse. 

In catarrhal dyspepsia there is pain and uneasiness in the stomach 
after eating, with tenderness on pressure. If flatulence coexists there 
will be temporary relief to the discomfort upon the eructation of gas. 

In ulcer there is a more or less constant feeling of soreness in the 
epigastrium. After the taking of food the dull pain is aggravated and 
becomes sharply localized. Frequently also there is pain in the back 
at the same point a little to the left of the spine and between the mid- 
scapular region and the lumbar vertebrae. The pain usually occurs 
sooner after taking food than in the case of cancer, and is more fre- 
quently relieved by vomiting. Attacks of gastralgia are not rare, and 
the pain may shoot down the arm. 

In gastric cancer pain may be wholly absent throughout the entire 



STOMACH, INTESTINES, AND PERITONEUM. 



503 



course of the disease, bat, as a rule, pain is more continuous than in 
ulcer, less severe, not so sharply localized, does not come on so soou 
after taking food, and is not relieved to the same degree by vomiting. 
Paroxysms of gastralgia are not so common. 

In acute gastritis the pain and its character vary with the intensity 
of the inflammation. If due to the irritation of some toxic agent 
which has been swallowed, the pain is severe and burning; if the result 
of imprudences in eating and drinking the pain is of a dull sickening 
character. In either case there is more or less tenderness on pressure. 
Sometimes in mild cases of catarrhal gastritis firm pressure from a 
broad surface affords at least temporary relief to the distress. 

Pain in the stomach is considered with reference to the taking of 
food. When it comes on soon after food it is usually due to organic 
disease of the stomach, as ulcer or carcinoma ; but it may be due to 
neurasthenia. It must not be confounded with the pain that occurs 
from two to four hours after meals, and is caused by intestinal indiges- 
tion or some pancreatic affection. 

Alterations of the Appetite. Loss of appetite or anorexia may 
be due to a number of diseases. It is present in all forms of organic 
disease of the stomach. It may or may not be present in gastric 
neuroses. Everyone is familiar with the loss of appetite due to 
nervous impressions, as emotions, anxiety, or mental care. It is of 
frequent occurrence in disorders remote from the stomach which modify 
the condition of the organ reflexly. In the section on Vomiting will 
be found statements showing the iufluence of central disease and disease 
of distant organs upon the stomach whereby vomiting is induced. 
Through the same channels and through the same mechanism, and 
hence by the same group of causes, loss of appetite may be produced. 
Loss of appetite is a constant accompaniment of the moderate gastritis 
which attends all fevers. Reference cannot well be made to all the 
conditions which induce this symptom. The writer has been particu- 
larly impressed with the importance of determining the presence or 
absence of suppuration in some portion of the body in all cases in 
which there is loss of appetite or disgust for food. 

Boulimia, or excessive appetite, sometimes occurs. It is popularly 
thought to be due to worms in children. It is a common symptom in 
diabetes, and is said to be present in disease of the mesenteric glands. 
It occurs also in gastric neuroses. Perversion of the appetite, in which 
all sorts of substances are swallowed greedily, occurs in hysteria, 
dementia, and pregnancy. It is known as pica. 

Regurgitation of gases or food matter is a frequent symptom of 
gastric disorder. It is also known as belching or eructation. It may 
be limited to the discharge of gas, although sometimes imperfectly 
digested food also rises. (See Rumination.) 

Regurgitation of the gastric juice alone causes an unpleasant taste, 
and the fluid is hot and acrid. The juice is usually brought up in 
the belching of gas. 

Pyrosis, or water-brash, is a common symptom in some forms of 
dyspepsia. It may occur in the morning when the stomach is empty, 
at which time large amounts of fluid are ejected. The fluid is thin 



504 



SPECIAL DIAGNOSIS. 



and watery, sometimes acid, sometimes tasteless. In other cases the 
fluid is slightly alkaline. The fluid is ejected without vomiting. Some- 
times the discharge begins immediately after eating. The late Dr. 
Chambers thought that the fluid was saliva which was swallowed and 
retained in the lower part of the oesophagus by a spasm of the cardiac 
orifice. When a sufficient amount is collected it gushes back into the 
mouth. Pavy and Handfield Jones believe that the fluid is secreted 
by the stomach, while, on the other hand, Roberts, who found the 
liquid to possess diastatic power, believes it to be due to saliva. 

Palpitation. Increased action of the heart is a common symptom 
of indigestion due to flatulency or an overloaded stomach. 

Hiccough, or singultus, is a spasm of the diaphragm. The contrac- 
tions take place at more or less regular intervals, attended with a pecu- 
liar clicking sound. This sound is due to the sudden passage of air 
through the glottis. Hiccough may be a serious symptom. It may 
last but a few minutes or continue for several days. It causes extreme 
exhaustion. Its occurrence in chronic disease is of bad prognostic omen. 

Constipation. This symptom will be discussed in the chapter on 
Intestinal Diseases. It is present with gastric dilatation. In pyloric 
stenosis it is always present. 

Diarrhoea. The digestion is impaired and peristalsis is in excess. 
Lienteric diarrhoea is an accompaniment of a gastric motor neurosis. 
In gastrectasia the fermentative products set up gastro-intestinal 
catarrh which induces diarrhoea. 

Acute G-astritis. 

The simple variety of acute gastritis varies in accordance with the 
cause, from a slight attack of vomiting after indiscretion in diet, with 
ordinary symptoms of indigestion, to the more severe forms ushered 
in by chill and attended by fever. 

In the mild forms there is a sense of fulness and discomfort in the 
epigastrium, attended with nausea. The appetite is lost and there may 
be disgust for food, and saliva is increased. There is undue acidity. 
On examination the epigastrium is found to be tender. With the 
onset of the attack there are giddiness, flashes of light before the eyes, 
frontal headache and some prostration. The pulse is increased in fre- 
quency. When the nausea is most pronounced the face is pale aud 
the extremities cold. Vomiting then occurs, the matter rejected con- 
sisting of ingesta only slightly changed, with mucus and watery fluid. 
It is very bitter. It is often colored green from bile-pigment. Another 
attack of vomiting may be sufficient to give relief, or it may be repeated 
for twenty -four to forty-eight hours every hour or two. After the 
stomach is relieved of the food, mucus and bile alone are vomited. 

Examination of Stomach Contents. The reaction of the vomited 
matter is neutral or faintly acid. No free hydrochloric acid is present, 
but later lactic and fatty acids are found. Pepsin is lessened. 

Twelve to twenty-four hours after the gastric symptoms begin, the 
intestinal symptoms may arise. Borborygmi and colicky pains are 
complained of, followed by diarrhoea with some tenesmus. 



STOMACH, INTESTINES, AND PERITONEUM. 



505 



Herpes labialis may occur, and some writers speak of a peculiar odor 
which is exhaled from the skin. The more severe cases are ushered in 
with chill followed by fever. The local symptoms are much aggravated. 
The tougue is furred, the breath is foul. The vomiting is frequent and 
severe. The skin is livid and the pulse becomes rapid. In the acute 
cases attended by fever it may be mistaken for meningitis, peritonitis, 
or hepatitis. The same gastric symptoms may usher in an attack of 
pneumonia. The possibilities of a mistake are to be borne in mind, 
and in all cases of vomiting with fever due regard must be paid to the 
possibility of the gastric symptoms being symptomatic only. It must 
be borne in mind that the same group of symptoms due to gastritis 
accompany the exanthematous diseases, diphtheria and dysentery, 
pyaemia and puerperal fever. They may be of reflex origin, or due to 
the action of fever, poison, or ptomaines on the stomach. Ewald calls 
it sympathetic gastritis in which the symptoms are the same as in the 
simple variety, masked, however, by the primary disease. Sometimes, 
however, as in the eruptive fevers, attention is directed to the state of 
the stomach to the exclusion of other conditions. And often to the 
surprise of the student an eruption or inflammation ensues, which indi- 
cates the true nature of the case. 

In cases of gastritis, therefore, endeavor to find a local cause for the 
symptoms. If there is no history of indiscretion in diet, of exposure, 
of exhaustion, or mental shock, on account of which digestion might 
be arrested, then inquire for a history of exposure to contagious 
diseases and look for the earlier evidences of exanthemata. If the 
pursuit for the cause is still unsatisfactory examine the condition of 
each individual organ, particularly bearing in mind meningitis, pneu- 
monia, peritonitis, and nephritis. 

Phlegmonous gastritis is a very rare affection, in which the inflamma- 
tion is seated in the sub mucosa and leads to perforation. The onset is 
sudden. The local symptoms are intense pain in the epigastrium, with 
a burning sensation. There is great acidity, dry tongue, and absolute 
anorexia. The fever is high and characterized by delirium. Chills 
usually accompany it. The pulse is small, rapid, and irregular. The 
matters vomited are first mucus, then pus. The patient is extremely 
restless and anxious, with delirium, and early passes into coma. Death 
takes place from collapse. It is impossible to make an absolute diag- 
nosis, as local peritonitis, or abscess of the liver are characterized by 
the same symptoms. In abscess a tumor may form in the epigastrium. 
It may occur idiopathically, but it frequently occurs in septicaemia, and 
follows trauma. 

Toxic gastritis is allied to the former in the severity of general symp- 
toms. It is the result of the swallowing of irritating poisons, of which 
phosphorus, arsenic, bichloride of mercury and caustic alkalies are the 
most common. It is attended by inflammation in the mouth, oesoph- 
agus and stomach. There is salivation and dysphagia. There is con- 
stant vomiting of blood, often with shreds of mucous membrane. The 
patient is restless, convulsions may occur, collapse rapidly develops. 
In mild cases, in which the local effects of the corrosive substance may 
have been mitigated by proper antidotes, sloughs separate, followed by 



506 



SPECIAL DIAGNOSIS. 



ulceration, which, when healing, result in deformity or stenosis of the 
canals. 

Some of the poisons are attended by other symptoms peculiar to the 
special poison. Thus, with arsenic, there are choleraic symptoms ; in 
phosphorus poison the symptoms come on late after its ingestion, and 
are attended by jaundice and symptoms of acute yellow atrophy. 

Mycotic and diphtheritic gastritis occur secondarily to typhoid fever, 
pneumonia, pysemia, smallpox and sometimes diphtheria. The mucous 
membrane may be covered with patches in areas or throughout its 
whole extent. 

Some special micro-organisms irritate the gastric mucosa, as the 
anthrax bacillus ; and the sarcinse and yeast fungi, in cancer and dila- 
tation of the stomach. Rarely tuberculous inflammation with ulcera- 
tion takes place, and other micro-organisms have been described, as by 
Klebs. This observer found the bacillus gastricus with numerous 
spores in the tubules. A gastritis was set up. 

The mucous membraue is free from the infection of micro-organisms 
because of the character of its secretion. The acid gastric juice is 
antagonistic and causes the death of micro-organisms. On this account, 
for instance, tuberculosis is rare in the stomach. 

Chronic Gastritis. 

Causes. 1. Previous attacks of acute gastritis. 

2. The local irritation of badly cooked or poorly masticated food, 
and of alcohol, or other drinks. 

3. The local irritation of urea in chronic Bright's disease, or of pro- 
ducts of putrefaction in constipation. 

4. In anaemia chronic gastritis is of frequent occurrence, and in 
venous congestions from any cause, but particularly disease of the 
heart or diseases which interfere with the portal circulation. It 
occurs secondarily to diabetes, gout, rheumatism, nephritis, and tuber- 
culosis. 

5. It is a constant attendant upon local disease of the stomach, as 
cancer, dilatation, and ulcer, or of local disturbance of the circulation. 

The symptoms are those of chronic indigestion. There is a dry, 
pasty, or salty taste in the mouth, especially in the morning. The 
tongue is coated over its entire surface, or at the base leaving red 
patches. The papillse of the tongue are always swollen and the edges 
of the teeth marked. Aphthse recur frequently. The lips are dry and 
often chapped. The appetite is poor, but varies from time to time. 
Although there is no great thirst the patients crave fluids with their 
meals, and acid drinks are grateful. After eating there is an oppression 
and distention in the epigastrium, followed soon by belching, which is 
of frequent occurrence. The gaseous eructations are odorless, or foul, 
and rancid regurgitatian is frequent, with pyrosis. The acidity is due 
to fatty and lactic acids and not to hydrochloric acid, as in hypersecretion. 
Vomiting is invariably present, but occurs irregularly. It is usually 
preceded by nausea. The most characteristic form is that in which 
mucus is vomited in the morning on rising. Constipation usually 



STOMACH, INTESTINES, AND PERITONEUM. 507 



exists ; it may alternate with diarrhoea. There is flatulency and 
rumbling iu the intestines. 

General Symptoms. The nervous symptoms are the most pro- 
nounced. The mental activity is diminished, there is a feeling of 
languor, or torpor, especially after eatiug. Headache is frequent 
after eatiug, and the patient may become morose and hypochondriacal. 
Attacks of vertigo are common. Itching of the skin and coldness of 
the extremities are not rare. Sleep is deeper and longer than we see 
it normally, but is disturbed by dreams, and not refreshing. Yawning 
is frequent. Pharyngitis usually attends the attack, on account of 
which there is hacking cough aud expectoration, or hawking of mucus. 

The pulse may be weak and irregular, and at times there is an even- 
ing rise of temperature. The urine is scanty, high-colored, and usually 
loaded with urates. 

Three forms are seen: (1) simple chronic gastritis; (2) chronic 
mucous gastritis; chronic catarrh of the stomach is applied to both 
conditions. If the condition lasts for a long period of time it results in 
(3) atony, with dilatation of the stomach, or with atrophy. Atrophy, or 
atrophic gastritis, is secondary to the chronic form, or to stenosis of the 
oesophagus, or cancer. The symptoms are those of pernicious anaemia. 
Cirrhosis of the stomach is also a sequence of gastritis. It is rare, 
and the symptoms are not characteristic of a special lesion. They 
are those of the primary disease. 

Examination of the Stomach Contents. In simple gastr itis the stomach, 
after digestion is completed, contains a small amount of slimy fluid. 
Hydrochloric acid is diminished in quantity after a test breakfast ; 
lactic acid and the fatty acids are present, as previously noted. Pepsin and 
the milk-curdling ferment are absent or diminished. In mucous gastritis 
there is subacidity. It differs from the simple form in the excess of 
mucus only. In atrophy the hydrochloric acid and pepsin are dimin- 
ished, or completely absent, after the test breakfast. The fasting 
stomach is empty. There are no fermentation acids. Atrophy must 
be distinguished from cancer and subacid neuroses. The latter occur 
in younger individuals than those subject to atrophy. A bloody tinge 
in the stomach contents, or hemorrhage, may be the only distinguishing 
mark of cancer. Often it is impossible to make a diagnosis. 

The diagnostic features of chronic gastritis are : first, long duration ; 
second, persistence of local symptoms; third, recurrence of local symp- 
toms after food, increased by stimulants, or stimulating food; fourth, 
pain is moderate ; fifth, cachexia is absent ; sixth, tumor is absent ; 
seventh, hemorrhage is rare ; eighth, vomiting may or may not be 
present, and hydrochloric acid is variable ; ninth, flatulency is almost 
always present. Finally, the cause is usually definite. 

Cancer of the Stomach. 

The clinical symptoms are varied. It may occur without any symp- 
toms whatever, and be discovered after death from other causes. On 
the other hand, general marasmus and cachexia may be present alone 
without local symptoms. In some cases the gastric symptoms are 



508 



SPECIAL DIAGNOSIS. 



slight and obscured by the symptoms of secondary growth in the liver 
or peritoneum. 

Typical cases are those which occur late in life, with symptoms of 
chronic gastritis. These symptoms may continue for months before 
anything further is observed. Gradually the uneasiness and discomfort 
after eating increases to actual pain. Loss of appetite is marked, and 
in spite of careful treatment there is loss of flesh and strength. 
The usual vomiting of chronic gastritis gradually becomes more 
frequent. The general appearances of the vomitus are at first like 
those of chronic gastritis. Soon it becomes streaked with blood, or a 
moderately large hemorrhage may take place. The vomited matter 
is dark in color, like coffee-grounds in appearance. The relation 
of vomiting to the time of taking meals depends upon the seat of 
the disease. If at the cardiac end of the stomach, the vomiting 
may take place at once. If in the greater curvature, within twenty 
minutes or one hour and a half after taking food. When at the 
pyloric orifice, the vomiting is delayed several hours after food is taken. 
As the disease advances and obstruction becomes complete at the cardiac 
orifice food is immediately regurgitated, unless secondary dilatation of 
the oesophagus takes place. When there is gastric dilatation the vomit- 
ing may take place at longer intervals and be characteristic of the 
vomitus of dilatation. Constipation is the rule. 

Tumor. After the symptoms of chronic gastritis have continued for 
some time without relief a tumor may be detected, depending upon 
its position and size (see page 478). If the disease is situated at the 
cardiac orifice of the stomach it is often impossible to detect the growth. 
If at the pyloric orifice, the tumor is found to the right of the median 
line above the umbilicus, but may be lowered by the weight of the 
stomach and felt at the umbilicus. When dilatation follows pyloric 
tumor it may be lowered still further, as in a case of the writer's, in 
which it was found two inches below and to the right of the umbilicus. 
In tumor of the greater curvature the mass is detected below T the 
margin of the ribs on the left side, and may be as low down as the 
umbilicus. If the greater curvature is involved the organ usually 
atrophies, and hence the physical signs indicating the lower border of 
the stomach are higher up than in health. 

Symptoms due to Metastasis. The liver is the most frequent seat of 
secondary growths. The organ enlarges and its surface is covered 
over with nodules. Jaundice rarely occurs. The enlarged liver may 
cover the stomach and hide the local mass. The inguinal glands enlarge, 
and at times there is enlargement of the supra-clavicular glands. 

The general symptoms are those of emaciation and cachexia. The 
anosmia becomes profound. The emaciation is extreme, and in some 
cases may be out of proportion to the local symptoms. If fever occurs 
in the course of the disease it is usually due to secondary accidents, as 
suppuration in a tumor, or perforation, with septic peritonitis. The 
usual course of the temperature is normal until the later stages, when 
it is subnormal. 

The symptoms of cachexia are those of emaciation and anaemia* 
The pallor of the face is striking, and often is of a yellowish and straw- 



STOMACH, INTESTINES, AND PERITONEUM. 



509 



colored hue. It must not be confounded with jaundice, and examina- 
tion of the conjunctiva is usually sufficient to distinguish the two. 
The skin is flabby and the subcutaneous fat is entirely lost ; the ema- 
ciation is not as marked as in cancer of the oesophagus, except when 
there is complete cardiac stricture. The nutrition of the skin suffers, 
boils are common, and ulcers may occur. Subcutaneous hemorrhages 
are seen in the terminal stages on the backs of the hands, on the dor- 
sum of the feet, on the legs and arms. There is slight oedema of the 
ankles. General atrophy of the internal organs takes place, so that the 
heart becomes small ; it loses in strength, the patient becomes weaker 
and weaker, the pulse rapid and feeble. 

Examination of the Stomach Contents. Hydrochloric acid is absent 
in nearly all the cases. For an accurate diagnosis repeated examina- 
tions must be made. Other general and local conditions, as fevers 
on the one hand or dilatation on the other, are attended by absence of 
hydrochloric acid at times. In carcinoma it is the persistence of the 
absence which is diagnostic. Pepsin and the milk-curdling ferment are 
not changed. Urine. Indicau in increased amount, acetone and diacetic 
acids, may be present in the urine ; otherwise there is no change. 

Diagnosis. In the diagnosis of gastric cancer the following must 
be borne in mind : 1. The age of the patient. 2. The occurrence 
of causeless dyspepsia without relief. 3. Rapid loss of flesh and 
strength, with cachexia. 4. The occurrence of pain in the epigastrium, 
continuous, increased by food, but not relieved by vomiting, as in 
ulcer, and not distinctly localized. 5. Tumor — hard, circumscribed, 
followed by the physical signs of dilatation, if in the pylorus. 6. Vom- 
iting is necessarily associated with the taking of food, in which frag- 
ments of cancer may be found ; blood-cells are common, as detected on 
microscopical examination, or with Gmelin's test. 7. Examination of 
stomach contents, (a) Except in dilatation, the fasting stomach is empty ; 
(b) hydrochloric acid usually absent ; (c) delayed absorption is present, 
indicated by the motor tests. 8. Hemorrhage. In small amounts, 
usually characteristic, coffee-ground appearance. 9. Metastases — above 
the left clavicle ; in the liver ; in the inguinal glands ; rarely in the 
lungs and peritoneum. 10. Eichhorst speaks of persistent itching of the 
skin and insomnia as characteristic symptoms. 11. Finally, the com- 
paratively short duration of the case. Earely does it extend over a 
period of two years. 

The Significance of the Tumor. If a tumor is present it is necessary 
to exclude tumors in the same situation from other causes. This is 
sometimes difficult. Indeed, as far as the location and physical charac- 
ters are concerned, often impossible. The most pronounced diagnostic 
feature of tumor of the pylorus is the occurrence of secondary dilata- 
tion. For a differential diagnosis of tumors in this region, see page 478. 



510 



SPECIAL DIAGNOSIS. 



Differential Diagnosis of Gastric Cancer, Gastric Ulcer, and 
Chronic Gastritis. (Welch.) 



Gastric Cancer. 

1. Tumor is present in three- 
fourths of the cases. 

2. Rare under forty years of 
age. 



3. Average duration about one 
year, rarely over two years. 

4. Gastric hemorrhage fre- 
quent, but rarely profuse ; 
most common in the cachec- 
tic stage. 



5. "Vomiting often has the pe- 
culiarities of that of dilata- 
tion of the stomach. 



6. Free hydrochloric acid usu- 
ally absent from the gastric 
contents in cancerous dila- 
tation of the stomach. 

7. Cancerous fragments may 
be found in the washings 
from the stomach or in the 
vomit (rare). 

8. Secondary cancers may be 
recognized in the liver, the 
peritoneum, the lymphatic 
glands, and rarely in other 
parts of the body. 

9. Loss of flesh and strength 
and development of ca- 
chexia usually more marked 
and more rapid than in ulcer 
or in gastritis, and less ex- 
plicable by the gastric symp- 
toms. 

10. Epigastric pain is often 
more continuous, less de- 
pendent upon taking food, 
less relieved by vomiting, 
and less localized than in 
ulcer. 

11. Causation not known. 



12. No improvement, or only 
temporary improvement, in 
the course of the disease. 



Gastric Ulcer. 
Tumor rare. 



May occur at any age after 
childhood. Over one-half 
of the cases under forty 
years of age. 

Duration indefinite ; may be 
for several years. 

Gastric hemorrhage less fre- 
quent than in cancer, but 
oftener profuse ; not uncom- 
mon when the general 
health is but little im- 
paired. 

Vomiting rarely referable to 
dilatation of the stomach, 
and then only in a late stage 
of the disease. 

Free hydrochloric acid usu- 
ally present in the gastric 
contents. 



Absent. 



Absent. 



Cachectic appearance usually 
less marked and of later 
occurrence than in cancer, 
and more manifestly de- 
pendent upon the gastric 
disorders. 



Pain is often paroxysmal, 
more influenced by taking 
food, oftener relieved by 
vomiting, and more sharply 
localized than in cancer. 



Causation not known. 



Sometimes a history of one or 
more previous similar at- 
tacks. The course may be 
irregular and intermittent. 
Usually marked improve- 
ment by regulation of diet. 



Chronic Catarrhal Gastritis. 
No tumor. 

May occur at any age. 



Duration indefinite. 



Gastric hemorrhage rare. 



Vomiting may or may not be 
present. 



Free hydrochloric acid may be 
present or absent. 



Absent. 



Absent. 



When uncomplicated, usually no 
appearance of cachexia. 



The pain or distress induced by 
taking food is usually less severe 
than in cancer or ulcer. Fixed 
points of tenderness usually ab- 
sent. 



Often referable to some known 
cause, such as abuse of alcohol, 
gormandizing, and certain dis- 
eases, as phthisis, Bright's dis- 
ease, cirrhosis of the liver, etc. 

May be a history of previous simi- 
lar attacks. More amenable to 
regulation of diet than is cancer.. 



Ulcer of the Stomach. 

Simple round ulcer of the stomach may occur at any age, but is most 
common in young anaemic women. It may be the result of an erosion 
of hemorrhagic infarcts by the gastric juice. Stockton believes it to be 
a neuropathic change. 

The Symptoms. The symptoms are variable. The cases have 
been divided by Welch into four classes: (1) Those in which there are 



STOMACH, INTESTINES, AND PERITONEUM. 



511 



no symptoms whatever, the ulcer having been found after death from 
other diseases ; (2) no symptoms until the sudden occurrence of hemor- 
rhage, or perforation ; (3) the symptoms of chronic gastritis or gastralgia 
only. The symptoms of ulcer may develop suddenly; (4) typical cases. 
Pain, hemorrhage, and vomiting are the characteristic symptoms. 

Pain. The pain is localized ; it is usually confined to a small area 
in the epigastrium. It may be seated behind the cartilages of the 
sixth and seventh ribs, or may be complained of in the back, between 
the eighth and ninth dorsal vertebrae, extending as low down as the 
first and second lumbar. It is of a burning or gnawing character when 
seated in the epigastrium, and is said to be gnawing when seated in the 
back. It is increased by food, and comes on in from two to ten minutes 
after the ingestion of food. It is relieved by vomiting, or after the act 
of digestion is completed ; but a persistent, dull pain or a feeling of sore- 
ness remains. In addition to the ordinary pains, there may be attacks 
of gastralgia. The pain is increased by pressure. It may be modified 
by the position of the patient. It may be relieved by lying on the 
back when the ulcer is in the anterior wall ; or relieved by lying on 
the abdomen when in the posterior wall. 

Vomiting. Vomiting occurs shortly after the ingestion of food. It 
is not attended by retching. The vomited matter may contain blood. 
The vomited matter and the contents of the stomach contain hydro- 
chloric acid, which may be in excess. Eichhorst thinks it is always in 
excess. 

Hemorrhage. Blood in the vomitus gives it a brown or reddish 
color. It may be detected by the usual methods. Hemorrhage may 
occur, however, independently of the act of vomiting. It varies in amount 
from half a pint to a quart. It may be so severe as to cause collapse. 
Sometimes, instead of the profuse hemorrhage of dark blood, it may 
gradually ooze from the ulcer and collect in the stomach before being 
vomited. It is then altered by the acid gastric juice. Sometimes the 
blood is not vomited, but passed by stool, which is tarry. Tarry stools 
also follow the vomiting of blood. In the course of ulcer a hemorrhage 
may be so severe that death takes place before vomiting occurs. The 
stomach is then found filled with blood. 

The stomach bougie should not be used, and the nature of the con- 
tents must be determined by an examination of the vomited matter. 

The General Symptoms. If the cases are of long standing, the 
face is anxious and the lines are sharpened. If there is much hemor- 
rhage, anaemia ensues. There is not much wasting, and there is no 
fever. Chronic dyspepsia and constipation may attend it during the in- 
tervals in which the severe symptoms are in abeyance. The period of 
abeyance varies and the symptoms may come on without cause, as in 
gastric crises, during which time the vomiting may persist for two or 
three days. I saw a young girl of twenty with most severe gastric 
hemorrhage and classical symptoms of ulcer. With careful treatment 
she improved. After marriage she remained well until pregnancy. 
During the first periods of this condition vomiting was very extreme ; 
it then subsided, whereupon, without warning, gastric crisis took place. 
The vomiting of blood continued for many days, and the symptoms of 



512 



SPECIAL DIAGNOSIS. 



gastric ulcer remained for a month. One of the characteristic features of 
the disease is the occurrence of symptoms which disappear, and after a 
long period of abeyance recur. A patient under my care, during the 
last ten years has had three undoubted attacks. It is possible that 
during each period ulcers healed, to be followed after a time by the 
occurrence of new ulcers. 

Diagnosis. The diagnostic features are : 1. The age. 2. The long 
duration. 3. The occurrence of emaciation up to a certain point only; 
most of the patients are under-weight and have a gaunt look, particu- 
larly males. 5. The characteristic pain. 6. The vomiting. 7. The 
hemorrhage. 8. The periods of relief from symptoms. 9. The absence 
of marked nervous symptoms which attend gastric neuroses. 10. The 
absence of dilatation of the stomach. 11. The hyperacidity of the 
gastric juice. 

The Accidents of Ulcer of the Stomach. 1. The occurrence of perfora- 
tion. Sudden severe pain, with collapse. The pain is usually in the 
epigastrium, but may be in the back as high as the seventh or eighth 
dorsal vertebrae. 

2. Hemorrhage, which may cause death immediately, with either 
vomiting of blood or with its retention in the stomach. 

3. With healing of the ulcer, stenosis at the pyloric orifice may take 
place with the occurrence of dilatation. 

Dilatation of the Stomach (Gastrectasia). 

It is caused by obstruction at the pyloric orifice, either from cancer, 
the cicatrix of an ulcer, or fibrous stricture. It follows atony or de- 
generation of the walls of the stomach which occurs in the course of 
chronic gastritis. It may attend paralysis of the stomach. Excessive 
eating and drinking is the only probable cause independent of organic 
disease. The dilatation may be acute. The term acute paralytic dis- 
tention is also applied to this condition. The cases are extremely rare. 
There is sudden enlargement of the upper portion of the abdomen, with 
pressure upon the surrounding structures. The heart is dislocated and 
its action is very much increased ; collapse attends the occurrence, and 
death takes place from this cause. At first there may be some belching, 
but the patient is soon unable to remove the gas, and hence occur extreme 
discomfort, palpitation and dyspnoea. 

Chronic dilatation develops slowly. The symptoms of it follow the 
causal disease. They are marked dyspepsia with flatulency, pyrosis and 
other symptoms of fermentation. If vomiting has attended the causal dis- 
ease and occurs frequently, its character changes as to frequency of occur- 
rence and the nature of the matter vomited ; it now occurs at longer inter- 
vals, the amount is excessive, greater than the normal stomach will 
hold, and is made up of food that is partially digested antl fermented 
and large amounts of mucus. The stomach contents contain sarcinae, 
torulse, and other products of fermentation. Hydrochloric acid is 
usually absent, but there is a large excess of lactic and fatty acids. 
With the above symptoms the patient loses flesh and strength and be- 
comes irritable, depressed, and more or less melancholy. The nervous 



STOMACH, INTESTINES, AND PERITONEUM. 



513 



symptoms of chronic gastritis are also present. In some cases there is 
excessive thirst because of the small amount of nutrition and fluid 
absorbed. Palpitation of the heart is common, and dyspnoea may occur 
on account of the distention. Tetany has been observed in cases of 
dilatation, especially after lavage. 

Physical Examination. The diagnosis is not complete without physi- 
cal examination. On inspection the abdomen is large and prominent, 
and the outline of the stomach can sometimes be seen. Peristaltic 
movements of the organ are often seen. The movement is from left to 
right. On palpation the peristalsis can be felt, and with one hand on 
the stomach, tapping with the other, a splashing sound can be de- 
tected. A tumor can sometimes be felt in the region of the pylorus, 
or below the umbilicus. On percussion, when the stomach contains 
gas a tympanitic note is heard. After drinking water, dulness may be 
detected between gastric and intestinal tympany if the patient stands up. 
The dull note disappears when he resumes the recumbent posture. The 
tympany extends high up in the chest on the left side, so that Traube's 
half-moon space is obliterated. It may extend as high as the fourth 
interspace on the left side. Cardiac dulness is raised, and the apex of 
the heart is lifted upward and to the left. In the axillary region the 
tympany may extend as high as the sixth rib. There is usually atrophy of 
the spleen, so that unless very careful light percussion is performed the 
splenic dulness cannot be brought out. The lower limit extends below 
the transverse umbilical line, and may even extend midway to the 
pubis. On auscultation, succussion can easily be elicited. Sometimes 
the sound is sizzling as if there were effervescence. Heart sounds may 
be transmitted clear and metallic over the tympanitic stomach. With 
auscultatory percussion the border of the stomach can often be defined 
accurately. Percussion must be commenced far away from the stomach 
limits and conducted toward it. 

Rupture of the Stomach. This may occur in diseased conditions of 
its walls, or in the healthy stomach from external violence. Pain fol- 
lowed by collapse occurs with almost immediate death. 



Functional Disorders of the Stomach. 

The Neuroses. Functional disturbances of the stomach are due to im- 
pairment of the motor power of the stomach, impairment of the secre- 
tory function or of the sensory function. The following table of 
Ewald, as stated by that distinguished authority, is a classification of the 
various neuroses midway between the symptomatic and the setiological : 



The Neuroses op the Stomach. 

1. Conditions of Ireitation. 



a. Sensory. 
Hyperesthesia. 
Nausea. 
Hyperorexia. 

Anorexia ex hyperesthesia. 

Parorexia. 

Oastralgia. 



b. Secretory. 
Hyperacidity. 
Hypersecretion. 



33 



c. Motor. 
Eructation. 
Pyrosis. 
Vomiting. 
Colic. 

Tormina ventriculi. 



514 



SPECIAL DIAGNOSIS. 



2. Conditions of Depression. 

Ansesthesia. Anacidity. Atony. 

Polyphagia. Insufficiency of the pylorus 

and cardia. 

3. Mixed Form. 
Gastro-intestinal neurasthenia (Dyspepsia nervosa). 

4. Reflexes from Other Organs upon the Gastric Nerves. 

Reflexes from the brain, eyes, spinal cord, kidneys, liver, sexual organs, and intestines manifest 
themselves in the forms mentioned in 1 and 2. 

It must not be supposed that each of the above-mentioned symptoms 
occurs separately in an individual, or that functional disturbances may be 
limited to alterations of the sensory and secretory, or the motor ap- 
paratus respectively. They do not occur, as Ewald states, as distinct 
independent diseases, but usually in groups "either appearing simul- 
taneously, or closely following one another during the course of the 
malady, passing before us like an ever-changing scene." They may 
arise directly from disease of the stomach or renexly from disease of 
other organs, as the brain, the spinal cord, uterus, kidneys, liver, eyes 
and nose. 

JEtiology. Gastric neuroses are of most frequent occurrence in 
women, and especially during the years from puberty to the menopause. 
From the twentieth year onward they are of most frequent occurrence in 
both sexes because individuals are subjected to the operation of causes 
which lead to neuroses at this period of life. The gastric neuroses 
occur in all conditions of patients. They are more likely to occur in those 
who are poorly nourished or anaemic; although persons who are distinctly 
robust are liable to have gastric neuroses. While more common in the 
residents of cities, they may occur in farmers and others accustomed to an 
open-air life. Although called upon to treat them most frequently among 
the better classes, nevertheless among the poorer classes a large number 
of cases are seen. To analyze more closely the predisposing causes 
we have to study individually all conditions and circumstances in life 
which lead to wear and tear, as in business or social affairs. In this 
country, particularly, the causes which Beard and others have forcibly 
pointed out as factors in the production of neurasthenia are especially 
prevalent, and are operative in the production of these neuroses. 

With regard to men, excess in business or dissipation ; in women, 
excesses in social life or the restraint of home cares, with, unhappily, too 
often, the irritation of marital relations, are the predisposing factors 
which lead to the development of this class of cases. Often patients 
among people of the large cities are subject to the neuroses in the spring 
after the dissipations of the winter. Behind this excess there is no 
doubt that a nervous temperament is in the majority responsible for the 
bringing out of the symptoms, particularly if, combined with this 
temperament, the patients live in au unhygienic way in regard to exer- 
cise, ventilation of their dwelling-places, and drainage, combined with 
improper diet. 

Symptoms. With the gastric neuroses other symptoms of neurasthenia 
are present, and usually the patient may seek advice for these symptoms, 
such as headaches of various kinds, changes in their mental condition, 
vertigo, insomnia, neuralgias and paresthesia of all forms. Intimately 



STOMACH, INTESTINES, AND PERITONEUM. 



515 



connected with the neurasthenic state is that of hysteria, and therefore in 
gastric neu ruses hysterical manifestations are most common. It may be 
impossible completely to define the border-line between neurasthenia and 
hysteria, and the gastric symptoms of the former are the gastric symp- 
toms of the latter. While on the one hand, therefore, general neuras- 
thenic symptoms are prominent, in order to accomplish a diagnosis upon 
which proper lines of treatment can be based, the condition of the 
individual must be viewed as a whole, and no one symptom or group of 
symptoms exaggerated in our minds. 

Ewald has divided the neuroses into those which arise from irritation, 
and those which arise from depression. The first result of irritation is 
hyperesthesia of the stomach, which is indicated by a feeling of fulness 
and tension, and of nausea. The sensation is allied to the normal, and is 
also seen in chronic gastritis, and in the sensations which attend hysteria, 
meningeal irritation, cerebral tumors, and other diseases of the nervous 
system. The increased irritability is such that the gentlest irritant 
excites discomfort or painful sensation. There is a continuous sensation 
of heat or cold, of gnawing, or pulling, or burning in the orgau. The 
local sensation reflexly influences the psychical life of the patient, so that 
hypochondriasis in some form attends it. The sensations may be 
relieved by food, to become worse if the stomach is emptied, although 
in the larger number of cases the trouble is aggravated during digestion. 
The sensations are likely to be aggravated by fasting a longer period than 
usual, or by restriction of the diet. Excesses may aggravate them, aud 
on the other hand they are said to follow debilitating states. Some foods, 
such as shell-fish, crabs and lobsters, or oysters, and strawberries, are 
likely to increase the peculiar sensations in the epigastrium, exciting mild 
depression, or burning, or even nausea. The excitation from these foods 
is usually due to peculiar idiosyncrasies of the individual. On account 
of the same idiosyncrasies pruritus, erythema and urticaria occur, with 
headache and some fever. 

Deviations from the Sense of Hunger. When hunger is exaggerated it 
is known as boulimia, or hyperorexia. It may be temporary or 
permanent. When permanent it is obstinate, weakening, and exceed- 
ingly unpleasant. It may occur alone or be a symptom of various 
diseases of the nervous system, manifest disease of the brain, neuras- 
thenia, hysteria, and psychoses. It complicates such disorders as diabetes, 
and may be of temporary duration in convalescence from acute disease. 
The disorder accompanies migraine, or hypochondriasis, and exoph- 
thalmic goitre. Analogous to it is perversion of the appetite, as seen in 
pregnancy, in children, and in mental disorders. 

Anorexia. Loss of appetite, or repugnance to food. In the first 
instauce, there is simply loss of appetite; in the second, there is 
repugnance toward food, or nausea at the sight of it. Loss of appetite 
accompanies dyspepsia in all forms. In the gastric neuroses it occurs 
spontaneously, or is due to hyperesthesia of the stomach, and therefore 
may arise from central or peripheral conditions of irritation. It is 
commonly seen following central nerve perturbation. The patient is 
hungry, and sits down to the meal fully prepared to satisfy himself. 
The first mouthful is at once followed by anorexia, which may almost 



516 



SPECIAL DIAGNOSIS. 



amount to nausea. On account of the loss of appetite or repugnauce 
the patient eats less and less of solid food, which results in disturbance 
of nutrition in a short time, soon affecting the higher centres. Profound 
mental disturbance may be an exciting cause, so that after the death of 
a friend, or shock of any kind, the patient is unable to take food. Loss 
of appetite may be the only manifestation of the gastric neurosis, but 
because nutrition is so seriously interfered with it results soon in the 
occurrence of other local or general symptoms. Fen wick points out 
that the relationship of it to emaciation and enfeeblement are such that 
grave organic diseases may be simulated. Thus it may be mistaken 
for phthisis, and general examination alone is sufficient to distinguish it. 

Gastralgia. Pain in the stomach occurs in organic disease, as in 
ulcer or cancer, or forms of gastritis. It also attends the gastric neur- 
oses, and may be the only symptom of this neurasthenic state. Such 
pain is functional, and is found in ansemic neurotic women. It may, 
however, occur in all classes. It is characterized by sudden pain in the 
epigastrium without regularity usually, though at times it may be dis- 
tinctly periodic. There may not be any definite relationship to the 
attack of pain and the taking of food, though it is most apt to occur 
when the stomach is empty. Some classes of food may aggravate it, 
though, in general, eating usually relieves the pain. If the epigastrium 
is examined it will be found to be free from tenderness, and indeed 
often pressure of the broad hand may be a source of relief. The pain 
is of an agonizing character, sometimes sharply localized, or again dif- 
fuse. It may even resemble the girdle sensation. On account of the 
severity of the pain the patient may be compelled to double himself up 
to relax the abdominal muscles. The breath is short, and speaking is 
done in a whisper. The attack is attended by more or less collapse, 
and the patient may complain of the sensation of impending death. 
There is pallor of the face, which is distorted with pain, and the brow 
is covered with perspiration. The pain may radiate along the spinal 
nerves in close situation to the stomach, and there is often vigorous 
pulsation of the abdominal aorta. 

The attack may last but a few minutes or continue for hours. It 
sometimes terminates suddenly with vomiting, or is relieved as soon as 
food is taken. After the attack the patient is exhausted and relaxed, 
and passes abundance of urine of low specific gravity. 

The gastralgias that are due to disease of the central nervous system 
are often most puzzling. Rosenthal has written exhaustively on this 
subject. Types of gastralgia of this character are seen in the gastric 
crises of tabes, first described by Charcot. Recent observers have found 
that it is due to sclerotic degeneration of the vagus nucleus. The 
patient is suddenly seized with severe pains, which may begin in the 
groin and ascend along both sides of the abdomen to the epigastrium, 
to which poiut they are fixed. Pain in the shoulders occurs at the 
same time. The pains are characteristic of lumbar ataxia in their 
lightning-like rapidity. With the pain the heart's action is increased 
in rapidity and force. There is no rise in temperature. At the same 
time there is uninterrupted and painful vomiting, which is attended by 
nausea and vertigo. The gastric pain may continue uninterruptedly 



STOMACH, INTESTINES, AND PERITONEUM. 



517 



for two or three days. It belongs to the pre-ataxic period, so called, 
but is almost sure to continue throughout the whole course of the dis- 
ease. The nature of the stomach contents bears no relation to the pain ; 
the frequency is variable. The pains may recur at long periods, or as 
frequently as once a month or once a week. Another special charac- 
teristic is the sudden relief that is given without cause. 

Neurasthenic Gastralgia. Neurasthenic gastralgia occurs in patients 
who are suffering from neurasthenia, and is divided by Rosenthal iuto 
two forms, the one irritative, the other depressant ; these are related 
by transitional forms. The early symptoms of neurasthenia (q. v.), 
and particularly in the irritative form with painful points in the 
nape of the neck and between the scapulae, or often lower down on the 
vertebrae, with neuralgias and paresthesia in the upper and lower extrem- 
ities, are attended by periodical recurring gastralgia. The gastralgia 
is characterized by a boring sensation which, during the attack, radiates 
over the lower ribs to the median line. It is accompanied by vaso- 
motor symptoms and symptoms of cerebral anaemia. In the depressant 
form the patient complains of weight and fulness, or a dragging sensation 
after eating, which is constant instead of paroxysmal. The neuralgic 
pains are not so marked, motor exhaustion is not so prominent, and the 
pain in the back is not as intense so in other varieties. In both 
instances on deep pressure over the region of the nerve plexuses which 
follow the bloodvessels in the abdomen, there is sharp and unpleasant 
pain radiating to the epigastrium. Burkart considers these painful 
points to be present in all cases, while Bichter believes that pressure 
over the stomach and abdomen is not painful. With such pain there 
is usually increased pulsation of the abdominal aorta, particularly dur- 
ing the time of the paroxysm. In neurasthenic gastralgias there is 
increased sensitiveness to the electrical current and increased stimula- 
tion of the sensory nerves of the trunk, which may also be extended 
to the limbs. 

Neurasthenic gastralgia must be distinguished from the gastralgia of 
orgauic disease and the gastralgia of hysteria. The gastralgia of organic 
disease is recognized by observing the condition of the stomach when 
fasting and by studying the secretion. In organic disease there is re- 
tarded digestion ; in gastric neuroses digestion is completed in the nor- 
mal limit of time, seven hours. Hysterical gastralgias are recognized 
by the presence of the usual symptoms of hysteria, in which the psy- 
chical factors occupy a prominent place, associated with convulsions, 
paralyses, pupillary inequalities, hemiansesthesia and electrical sensi- 
bility. Most characteristic, however, is the alternation of hysterical 
gastralgia with neuralgia, or neuroses in other organs. 

Hyperacidity and Hypersecretion. Hyperacidity is the increase 
of the normal amount of hydrochloric acid secreted, due to a neurosis 
of the secretory function. Hyperacidity begins when the amount of acid 
in the fluid withdrawn from the stomach in the usual way is between 60 
and 70 per cent. It must not be forgotten that it is a symptom of gastric 
ulcer, but it exists as a neurosis independent of any organic lesion of 
the stomach. It has been observed in nervous diseases, as hysteria and 
melancholia, and as a reflex symptom in gall-stones and renal calculus. 



518 



SPECIAL DIAGNOSIS. 



Hypersecretion occurs in two forms, the periodical and the constant. 
The acid is not necessarily increased. The periodical occurs after eating ; 
it does not have direct connection with food. It is seen in neurasthenia 
or locomotor ataxia. In chronic hypersecretion the gastric juice, which 
is usually hyperacid, is in excess, so that the fasting stomach may 
contain large quantities, even to a pint and a half, without food and 
only slightly tinged by bile. In chronic hypersecretion the digestion of 
starches is delayed, but that of albuminoids is very prompt. After an 
abundant meal consisting of meat and starches the meat disappears 
entirely. Hypersecretion occurs in about half of all the stomach dis- 
orders, according to Riegel. It is more common in men than in women. 
The acid fluid causes the hypersesthetic conditions previously described 
in the gastric region. Pain and eructation, heartburn, or gastralgia, 
vomiting of sour masses, occur with the digestive disturbances of chronic 
gastritis. The tongue is usually clean and the appetite increased rather 
than diminished. Acidity is common. As a result, atony of the mus- 
cular coat takes place, followed by gastrectasis. The neurosis is then 
converted into an organic lesion, and the symptoms of dilatation arise. 

In order to make a diagnosis the secretions must be secured while 
fasting. The patients usually improve on albuminous food, which 
differentiates it from gastralgia and pyrosis of acid fermentation. 
Alkalies give temporary relief. 

Grastroxynsis is a gastric neurosis in which, after mental over-exertion 
or profound emotional disturbance, there is sudden vomiting, continu- 
ing for a considerable time, of acid fluid. It is closely allied to 
migraine. Nervous belching and eructations are phenomena of the 
gastric neuroses of motor origin. They usually occur in hysterical sub- 
jects rather than in neurasthenics. In the latter they are associated with 
other sensations, particularly oppression and tension in the epigastrium. 
In hysteria they occur alone. There is increase in the contractility of 
the stomach, the pyloric sphincter contracts powerfully, and the stomach 
is distended ; gas is expelled at the cardiac end of the stomach. They may 
be due to paralysis of the cardiac end of the stomach rather than con- 
traction of the pyloric end. They occur involuntarily generally. They 
must not be confounded with the pseudo-hysterical vomiting which 
Bristowe has described. In this instance the gas is raised from the 
oesophagus by contraction of the muscles of the neck. Hysterical 
eructation is very frequently of oesophageal origin. The belching is 
loud and may occur in paroxysms. The gas is odorless, and hence is 
distinguished from the gas of dyspepsia and fermentation ; it is in all 
probability the result of the swallowing of air. 

Pyrosis, heartburn, is the raising of sour masses from the stomach. 
The stomach contents are not necessarily hyperacid. If acid, as in the 
normal gastric juice, or hyperacid, the regurgitation causes severe 
acrid and burning sensations. It is probably due to heightened con- 
tractility of the muscular coat of the stomach with pyloric contraction, 
which overcomes the weaker cardia. 

Pneumoptosi. Excess of gas in the stomach. When the stomach is 
overdistended, in addition to the tension, the diaphragm is pushed up, 
pressing on the heart. The patients are seized with severe dyspnoea. 



STOMACH, INTESTINES, AND PERITONEUM. 



519 



At first inspiration is difficult, and finally both inspiration and expira- 
tion become difficult. Palpitation of the heart and pulsation of the 
peripheral arteries take place. There is fulness of the head and a 
sensation of impending death. The patient may become unconscious. 
Relief can only be afforded by belching, when the attack rapidly sub- 
sides. Introducing a stomach bougie gives immediate relief. 

Nervous Vomiting. (See Subjective Symptoms, and Gastroxynsis.) 

Peristaltic Unrest. Characterized by borborygmi and gurgling, 
which begin immediately after eating, are heard at a considerable dis- 
tance from the subject, and are a source of great annoyance. It is a 
common symptom of the gastric neuroses. 

Rumination. Rumination is a rare condition in which the patients 
regurgitate and chew the end like ruminants. 

Conditions of Depression. In conditions of depression poly- 
phagia, or the want of a feeling of satiation, which, if gluttons are 
excluded, is a morbid condition of extreme rarity. 

Anacidity of the gastric juice as a neurosis is found in hysterical 
persons and in neurasthenics. (See Absence of Hydrochloric Acid.) 

Relaxation of the Cardiac and Pyloric Ends of the Stomach from 
Conditions Resembling Paralysis. When the cardiac end is relaxed, 
eructations and regurgitations occur. If large quantities of the material 
from the stomach are regurgitated and expectorated, the condition is 
pathological. It may lead to serious changes in nutrition. It may 
exist for years without bad results. It must not be confouuded with 
the regurgitation from diverticula of the oesophagus. In the latter 
regurgitation is produced at will. 

Rumination (Merycismus). See above. 

Atony, or Atonic Dyspepsia. It accompanies gastritis ; it also occurs 
as a primary neurosis. The innervation of the nerve centres regulating 
peristalsis is disordered. The primary disorder may be local or central. 
The movement of the chyme is tardy or insufficient. Atony should be 
applied to the disease of the motor function only, or, as Rosenbach 
states it, to insufficiency of the stomach. The symptoms develop 
gradually. At first occurs oppression during digestion, with swelling 
and fulness of the stomach. There is mental and physical torpor during 
the time of the digestive act. The symptoms become aggravated, and 
eructations occur, vomiting begins, and gradually the fermentative 
symptoms become most pronounced. At this period it is putrid, or 
fermentative dyspepsia. By the usual tests the motor power of the 
stomach is found to be diminished. The secretions are also scanty. 

Nervous Dyspepsia. According to Ewald this is the true gastric 
neurasthenia, which combines all forms of gastric neuroses. The 
clinical picture is made up of a combination of all the neurosal symp- 
toms mentioned. Leube considers nervous dyspepsia a group of symp- 
toms of a cerebral nature due to abuormal irritability of the sensory 
nerves of the stomach during the normal digestive processes, the symp- 
toms of which are hyperesthesia and nausea, hyperorexia, anorexia, 
parorexia, and gastralgia. Leube thinks the true peptic activity of 
the stomach is unchanged. While the anatomical or physiological ex- 
planation of the conditiou is difficult, the clinical symptoms are those 



520 



SPECIAL DIAGNOSIS. 



of irritation or paralysis, the manifestations of which are intermingled, 
sometimes one and sometimes another being most prominent. (See 
table, page 513.) 

The one characteristic feature is that the symptoms are mild. 
With severe forms of gastralgia nervous vomiting and boulimia do 
not occur. Symptoms of intestinal indigestion are usually associated 
in a mild degree. Constipation is of the most common occurrence, 
although in some cases there is diarrhoea. In other cases the intestinal 
indigestion is much aggravated with mild gastric disturbances and 
anorexia, repugnance toward taking food, furred tongue and mild 
nausea; and there are constipation and colicky pain, either diffuse or 
in separate painful spots. The abdomen is distended and tympanitic, 
sometimes to a marked degree. It is called flatulent dyspepsia. 
Along with the gastric and intestinal symptoms the general nervous 
symptoms to which the term neurasthenia is applied are present. 
These nervous manifestations sometimes precede the local gastric 
symptoms, but as the latter develop the former become more aggra- 
vated. The dyspeptic conditions, as Ewald puts it, are on a neurotic 
basis, or such as may occur as reflex neuroses in chlorosis, menstrual 
disorders, uterine and ovarian disease, and intense psychical excitement. 
Where pathological and anatomical changes are lacking, as far as is 
known great alterations in the chemical functions are absent. An indi- 
gestion of short duration, a mild catarrh, recurring hypersemia, have 
been the primary causes of nervous symptoms in the digestive organs. 

Diagnosis. There are no characteristic symptoms, and the student 
must bear in mind that it may be necessary to make several examina- 
tions and listen to the story of the subjective symptoms frequently 
before a complete conclusion can be arrived at. This is all the more 
necessary because of the frequency of organic lesions and neurasthenic 
conditions being present at the same time. The course of the disease 
must be observed for a long time, all possible causal factors investi- 
gated and all the general signs of neurasthenia carefully considered. 
In addition it may be necessary to use therapeutic tests. If the 
possible organic diseases are not relieved by such measures there 
must be a deeper basis for the gastric symptoms. Just as in neuras- 
thenia and in neurasthenic states elsewhere, the individual must be 
considered as to peculiarities, idiosyncrasies, and all his relations in life, 
in connection with the general and local symptoms of the neurasthenic 
state. Great stress must be placed upon the study of individual symp- 
toms, their mutual relationship and their changeable occurrence. In 
gastric neurasthenia, gastralgia is more diffuse than the pain of ulcer 
or cancer of the stomach. It is not so much dependent upon food as 
either of the others, particularly ulceration. In gastric neurasthenia 
vomiting is rare. The vomitus is composed of mucus mixed with bile 
and food in various stages of digestion. It is never bloody nor does it 
contain decomposed masses. Hysterical vomiting occurs with ease and 
regularity compared with the vomiting of neurasthenia. The vomiting 
in neurasthenia is bitter, due to the presence of peptones. In gastric 
neurasthenia the stools are changeable in character. They do not con- 
tain undigested remnants of food, or mucus, or blood. The form of the 
faeces is variable. 



STOMACH, INTESTINES, AND PERITONEUM. 



521 



Differential Diagnosis. Neoplasms, ulcers, strictures, dilatations are 
distinguished by physical signs or characteristic symptoms. In gastric 
neurasthenia the stomach should be empty seven hours after taking 
a meal. The results of the chemical examination are not sufficiently 
definite for diagnostic purposes, for at times the same chemical chauges 
are present as in ulcer, carcinoma, and chronic catarrh. The diagnosis 
must be based largely, as previously intimated, upon prolonged observa- 
tion and a carefully taken history, and upon the general condition of the 
patient. The cases must not be mistaken for costal neuralgia, although 
it is not usually easy to be led astray. Reflex gastric neuroses are seen, 
as indigestion, gastralgia, or vomiting. The types are interchangeable, 
although vomiting occurs in the more acute reflexes, indigestion in the 
more chronic. The cerebral disorders which give rise to vomiting are 
meningitis, abscess, and tumor. The vomiting may be transitory, or 
may be persistent. There is usually hypersecretion of the gastric juice. 
The vomiting may usher in the disease or develop during its course. If 
vomiting is of long-standing its possibly reflex origin should always be 
investigated. (See Vomiting, page 497.) 

Gastralgia is sometimes a reflex from lesions in the cervical and dorsal 
portions of the cord ; not only in the posterior columns, but also in 
disseminated sclerosis. Vomiting occurs, and the attack is known as 
a gastric crisis. 

Chronic dyspepsia is a frequent reflex disorder on account of diseases 
of the sexual organs, as amenorrhcea and dysmenorrhoea, in the cli- 
macteric period, and in chronic inflammations of the uterus. In mal- 
positions and tumors, and in pelvic exudations with traction, in ulcers, 
in ovarian tumors, the so-called dyspepsia uterina of Kisch is common. 

The Stomach in Other Diseases. Diseases of the stomach may 
frequently mask other diseases ; in other words, patients will complain 
of gastric symptoms which, however, are concomitant phenomena, behind 
which there are graver conditions. Thus, in disease of the kidney, in 
phthisis, in chronic gastritis, in emphysema, in valvular disease of the 
heart, catarrh of the mucous membrane of the stomach is of frequent 
occurrence, depending upon the primary disease. In tuberculosis 
the local gastric symptoms often seem to be the more prominent 
features. Thus, in the earlier stages of phthisis, loss of appetite and 
vomiting are of constant occurrence. The dyspeptic symptoms in a 
large number of cases precede the pulmonary symptoms and may 
be so pronounced as to mask entirely the symptoms of the latter 
disease. The patients are usually delicate and anaemic ; they complain 
of loss of appetite and mild indigestion ; there is some regurgitation of 
food ; they are feeble and languid ; they are treated for chronic catarrhal 
gastritis, but do not improve. On examination of the lungs the phy- 
sician is surprised to find a small area of consolidation, and upon inquiry 
will find subjective symptoms of tuberculosis to have been present for a 
considerable time. Every practitioner is familiar with the scores of 
patients with phthisis, which may even be advanced, who believe that 
their symptoms are entirely due to disorder of the stomach. In addition 
to the early catarrh that precedes tuberculosis, other gastric symptoms 
may occur. The well-known association of ulcer in phthisis is familiar, 



522 



SPECIAL DIAGNOSIS. 



although there is probably do causal relation, because both occur at the 
same time in life, yet the gastric symptoms may prevent investigation 
into those of pulmonary origin. In ancemia and chlorosis the changes 
in the digestive tract are common. On account of the general blood 
condition the functions of the stomach are impaired. Here, too, we 
frequently have the association of ulcer with the general condition. 
Danger of overlooking either is not so great as in tuberculosis. 

Valvular Affections of the Heart. Chronic catarrh of the stomach is 
liable to occur on account of venous congestion ; the symptoms may 
point to the gastric condition alone. In all cases of chronic gastric 
catarrh it is necessary to examine carefully into the condition of the 
heart. Over and over again patients apply for treatment on account 
not of cardiac symptoms, but because of gastric disorder. They will be 
treated in vain unless the primary affection is ascertained. Many cases 
of gastric catarrh have been cured by the use of digitalis. In disease 
of the kidneys, the stomach is frequently involved. Vomiting and 
other symptoms of gastric indigestion may occur long before dropsy or 
any objective sign which would lead to a correct diagnosis. The gastric 
symptoms are due to chronic ursemia. In other conditions of the genito- 
urinary tract, gastric symptoms also occur. This is particularly notice- 
able in long-standing retention from chronic obstruction. Renal tumors 
may cause only disturbances of digestion, while gastric symptoms due 
to movable kidney are well known. The symptoms in the latter con- 
dition arise, first, from mechanical causes, as the pressure of the kidney 
on the pylorus, and secondly, from the influence on the nervous system. 

Disease of the Liver. The intimate relationship of the liver and the 
stomach is such that when one is the seat of serious functional disturb- 
ance the other is likely to be affected. Frequently it is impossible to 
draw fast lines as to which organ is the primary seat of disorder. In 
the use of alcohol chronic gastritis is of frequent occurrence, and this 
intoxicant also causes cirrhosis of the liver. On the other hand cir- 
rhosis of the liver is frequently accompanied by chronic gastritis 
secondary to a portal congestion. 

Diseases of the Central Nervous System. The relationship of disease 
of the central nervous system to those of the stomach has frequently 
been adverted to. (See Vomiting.) In sclerosis of the posterior col- 
umns of the cord this is more striking than in any other condition. Not 
only do we have gastralgia and gastric crises, but moderate symptoms 
of indigestion, with hyperesthesia and slight gastralgia, may be the 
first symptoms of lumbar ataxia. 

Diabetes. Diabetes may continue in its course for a long period of 
time, during which the patient is thought to have some stomach trouble, 
when an examination of the urine reveals the true nature of the case. 
In gout and the rheumatic diathesis opinions differ as to the relationship 
of the stomach to this disorder. Some writers are full of the belief 
that a specific gouty inflammation of the stomach, due to the uric acid 
diathesis, is of frequent occurrence, and that one of the prominent mani- 
festations of gout is dyspepsia in all its forms. The French consider 
gastric disturbances to be frequeut expressions of the rheumatic diathesis. 
The relationship of the two, however, is thus far not fully developed, 



STOMACH, INTESTINES, AND PERITONEUM. 



523 



although, in these conditions, it is not usual to overlook the presence of 
either of the diatheses when symptoms of gastric disturbance occur. It 
is essential to bear in mind that in persons of a rheumatic or gouty 
diathesis gastric disturbances are as liable to occur as in healthy indi- 
viduals; their successful management depends upon the recognition of 
the fundamental diathesis. 

Diseases of the Intestines. 

The intestine is a canal of varying dimensions, the physiological 
office of which is to propel material received from the stomach, and to 
permit of the digestion and absorption of that which is to serve for the 
nutrition of the body. The canal is richly supplied with bloodvessels 
and lymphatics. It is made up of mucous membrane, muscle and peri- 
toneum. For the purpose of digestion, fluids are secreted, either from 
the intestinal glands or large neighboring glands which discharge into 
the canal. 

Diseases which affect the canal impair or cause an abeyance of the 
physiological offices. As these offices — absorption and digestion — are 
essential to nutrition, it is not surprising that the body weight and 
strength are impaired. We know too little about the function of diges- 
tion to utilize such knowledge in diagnosis. Intestinal digestion is also 
dependent upon the healthy performance of the functions of the liver 
and pancreas. It is difficult to draw fine lines of distinction even in 
health, and intestinal pathology is closely interwoven with hepatic and 
pancreatic pathology. 

Alterations of the function of the intestine as a canal give rise to 
distinctive symptoms. Either its movements are too frequent and 
rapid, causing diarrhoea, or too sluggish, causing constipation. Ob- 
struction of the canal leads to symptoms common to such a condition 
(see Morbid Process), modified by the physiological duties and the 
anatomical structure of the canal. 

The morbid processes are hyperemias, inflammations, degenerations 
and new growths. The symptoms that attend these processes are not 
different from the symptoms that attend such processes in similar 
structures elsewhere. It must not be forgotten that the function of the 
canal is influenced by each process. On account of the process we may 
have pain and/euer; on account of impaired function, pain, flatulency, 
diarrhoea or constipation, change in the character of the stools, and im- 
paired nutrition. Some of the above morbid processes may lead to the 
mechanical condition, obstruction. 

The morbid alterations of the intestinal tract are ascertained by 
data derived by inquiry and by observation. The data derived by 
inquiry include the subjective symptoms — pain, and discomfort from 
flatulency. By observation, the general condition of the patient is 
noted, the presence of tenderness, alterations in the size and shape of 
the abdomen, and other physical phenomena observed. The faeces are 
carefully studied, with the object of determining modifications of the 
function of the bowel, the presence of ingredients due to some morbid 
process, as serum, blood, pus, or mucus, or of extraneous matter, as 



524 



SPECIAL DIAGNOSIS. 



worms or foreign substances. The faeces are studied by the naked 
eye, by the microscope, and by bacteriological methods. 

One symptom may be the chief manifestation of a disease, as pain of 
lead colic; diarrhoea of several morbid disorders; constipation of others. 
In the discussion of the special symptoms a consideration of the diseases 
of which the symptom is the main expression will be taken up. 

The long channel is the recipient of material for nutrition, which may 
contain parasitic forms of animal life or their ova or spores, which enter 
the body in this manner. They remain in the intestinal tract or wander 
into other structures. They include animal and vegetable parasites. 
To the class of parasites belong forms of protozoa, vermes, and fungi. 
While the canal is open to infection by various micro-organisms, it is 
the natural habitat of others which may become deleterious agencies 
when the conditions of the environment of the parasite are changed. 
Thus the bacillus coli communis is, in man, with normal epithelial 
structure and normal secretions, an innocuous parasite which, when 
inflammation sets in, may become nocuous. 

The symptoms of the protozoa and fungi, or of their products, the 
ptomaines, are of an infectious or toxic nature. Inflammation is pro- 
duced locally, while general infective or toxic symptoms occur. 

The symptoms of worms, if retained in the intestinal canal, are — 

1 Reflex in nature; (2) symptoms due to catarrhal inflammation; 

(3) symptoms due to the action of the parasite on the blood — anaemia; 

(4) symptoms due to wandering of the parasite, as in trichinosis. (See 
Faeces.) 

Symptoms of the Tcenice and Bothriocephali. There may be no 
symptoms save discharge of the parasite or portions of it by the rectum. 
In others the symptoms of intestinal dyspepsia or intestinal catarrh are 
observed. Headache, giddiness, lassitude, and itching at the nose and 
at the anus are said to be present. The patient becomes hypochondri- 
acal. Convulsive disorders occur. Hysteria, forms of epilepsy, grind- 
ing of the teeth at night, and restlessness attend the habitation of the 
parasite in the intestine. In all convulsive disorders, the possibility of 
worms as a cause must be remembered. 

Symptoms of Ascarides. (1) Gastro-intestinal catarrh; (2) symptoms 
of obstruction (rare); (3) symptoms due to wandering — as to the hepatic 
duct or to the stomach, to the vagina ; (4) nervous symptoms of reflex 
origin; (5) the worm or its ova in the faeces. 

Symptoms of Oxyuris Vermicidaris. (1) Gastro-intestinal dyspepsia 
or catarrh ; (2) itching or heat at the anus, worse in bed ; (3) vesical 
and rectal tenesmus; (4) erythema about the anus; (5) priapism; (6) 
vulvitis and vaginitis; (7) the worms in the faeces. 

The Strongylus. The symptoms are local, with the symptoms of 
profound anaemia. The discovery of the ova in the faeces distinguishes 
this form of anaemia from other varieties. 

The symptoms due to the presence of the trichina spiralis and filaria 
will be discussed in appropriate sections. (See Blood and Geueral 
Diseases.) 

The intestines in other diseases. The relationship of intestinal dis- 
orders to affections of other viscera will be discussed with each symp- 



STOMACH, INTESTINES, AND PERITONEUM. 



525 



torn. It must not be forgotten that derangement of this tract may 
have its origin in local causes or in causes remote from the intestiDal 
tract, or in some general condition of the individual. Thus diarrhoea 
may be due to inflammation which is primarily local, or which may be 
secondary to infection. Nothing is more common than to see diarrhoea 
with general infection, as septicaemia. In exophthalmic goitre the diar- 
rhoea is not due to a local cause, but to some, not yet known, nerve dis- 
order. Constipation may be due to central brain disease, to a general 
condition like diabetes, or be of local origin. 

It must be remembered that the diagnosis of an intestinal lesion is 
never complete without determining its causes. Thus enteritis and 
ulceration occur in typhoid fever, in cholera, and in other infectious 
disorders, all of which are to be passed in review in making up a diag- 
nosis. Diarrhoea is a symptom in Bright's disease, and the causal 
relationship must always be borne in mind. 

Intestinal diseases or disorders are not usually confounded with dis- 
ease of other structures. It is worthy of remark that symptoms of 
intestinal obstruction are frequently due to peritonitis, the latter con- 
dition being overlooked. Tumors of the intestine must be distinguished 
from tumors of the peritoneum, the stomach, pancreas, and liver, and the 
uterus and ovaries. The history, the seat and physical character of the 
tumor, and the associate symptoms, point to the true condition. 

Arteries of the Intestine. The intestines are supplied by the mesen- 
teric arteries. Its branches may become the seat of emboli. The symp- 
toms are sudden pain, intestinal hemorrhage, and discharge of a por- 
tion of intestine. The patients are the subjects of atheroma or heart 
disease. 

The Data Obtained by Inquiry. The Subjective Symptoms. 

Pain. Colic. Colic is the term applied to paroxysmal pain in the abdo- 
men. It is further characterized by suddenness of onset and by alteration 
of intestinal function. It attends all forms of inflammation of the in- 
testinal tract. It is applied to a peculiar affection known as lead colic, 
due to the local effects of lead. Enteralgia should, however, be applied 
to this form. The term colic is also applied to painful affections of the 
hepatic ducts, pancreatic ducts, the ureters, and the uterus. Intestinal 
colic is the form at present referred to. In addition to the inflamma- 
tions of the intestinal tract it may be due to indigestion with flatulency. 
When it occurs suddenly without local cause it is known as enteralgia. 
It is a nervous affection. 

The colic of intestinal indigestion occurs suddenly, or may be pre- 
ceded by signs of intestinal indigestion. The pain is chiefly in the 
umbilical region and radiates from that point. It is relieved by 
moderate pressure or by warmth. The patient is restless and irritable. 
The face is anxious. The pain causes him to roll about and double up. 
There is a cold sweat, and the pulse is small and hard. Nausea and 
vomiting follow the pain, and there are gaseous eructations. The 
abdomen is distended from gas, and tympanitic on percussion. Prostra- 
tion or collapse rapidly ensues. The pain may be relieved by the passing 



526 



SPECIAL DIAGNOSIS. 



of flatus. With the local pain there is spasm of the muscles of the 
calves. The cramps are very painful ; the muscles become knotted. 
The hands and feet are also cramped. The pain is said to be due to 
spasm of the intestine, and is known also as spasmodic colic. It is 
certainly due to distention or to irritation. 

If the intestinal colic is due to indigestible food it may have been 
preceded by an attack of acute indigestion, and the griping pains may 
have developed at long intervals, with gastric and intestinal flatulency. 
Vomiting may precede or attend the attack, and diarrhoea follow. If 
the colic is due to gas alone there is great tympanites. If it is due to 
faeces it has been preceded by a history of constipation, and there may 
be faecal masses detected in the rectum or along the colon. 

Diagnosis. The sudden severe pain, often relieved on the discharge 
of gas, with gastro-intestinal disorder, tympanites, the occurrence of 
cramps in the extremities, and the localization of pain to the umbil- 
icus, all point to the true nature of the affection. A history of 
indiscretion in diet, or exposure, aid in the diagnosis. In colic the pain 
may come on suddenly or increase gradually from a sense of discomfort 
or soreness. The pain at its height is described as agonizing, and of a 
boring or shooting character, abating for a time and then increasing 
until the patient rolls and twists in agony and breaks out into a cold 
sweat. The pain may shoot from the seat of greatest intensity to the 
shoulders, back, chest, or iliac region. 

It must be distinguished from enteralgia. The latter comes on 
slowly and lasts for hours or days. The pain is situated around the 
umbilicus, it is relieved by deep pressure, although the skin may be 
hypersesthetic. Sometimes the abdomen is retracted ; there are no signs 
of indigestion, and flatulency and borborygmi are absent. 

Lead Colic. If the enteralgia is due to lead there is a history of 
exposure to that metal. The blue line on the gums, with obstinate 
constipation but no vomiting, and the occurrence of neuritis in other 
situations, due to saturnine poisoning, point to the true nature of the 
case. 

Hepatic Colic. In hepatic colic the pain is situated in the region of 
the liver and may radiate to the shoulder or back. It is sometimes 
fixed in the parasternal line about the cartilages of the sixth and 
seventh ribs. The attack is attended by vomiting, usually of bilious 
fluid. It occurs in women most frequently ; almost always after forty 
in both sexes. It may be followed by jaundice. There is local tender- 
ness, and there may be some swelling in the region previously men- 
tioned. The bowels are constipated, and after the attack may contain 
gall-stones. 

Renal Colic. In renal colic pain begins in the kidney and then 
extends along the ureter. It is always more localized to the right or left 
of the median line in the abdomen. It is more frequent in the lower 
portion of either of the upper quadrants, three inches to either side of 
the median line, depending upon the kidney affected. From this region 
the point of maximum intensity and of local tenderness moves to the 
lower quadrant toward the median line in the oblique direction, rarely 
getting an inch below the transverse umbilical line. The pain then 



STOMACH, INTESTINES, AND PERITONEUM. 



527 



extends to the region above the pubes and down the thighs. From the 
first there is increased frequency of micturition. The urine is scanty, 
high-colored, and may contain blood. With the free micturition relief 
follows. 

Local Peritonitis. Pain connected with the liver, spleen, and kidneys 
is generally due to involvement of the peritoneal coverings of these 
organs, and partakes of the character of local peritonitis. It may, how- 
ever, be due to malignant, ulcerative, or inflammatory disease, and the 
diagnosis must be made by noting the character of the pain, its in- 
tensity, duration, seat, and the other general and local symptoms with 
which it is associated. 

Rectal Pain. Pain in defsecation may be due to piles, internal or 
external, or to fissure, or may be the result simply of the passage of an 
unusually large, hard mass. Pain from fissure is most acute and 
spasmodic, and persists for some time after defsecation. Fibroid stricture 
of the rectum causes more pressure and straining at stool than real pain. 
But cancer is apt to be extremely painful. 

Uterine Colic. In uterine colic the pain is situated in the pelvis. 
There is some abnormality of discharge, and a history of uterine disease. 
Care must be taken not to confound the sudden pain of extra-uterine 
pregnancy with intestinal colic or other forms of abdominal pain. In 
extra-uterine pregnancy the pain is in the lower quadrants of the abdo- 
men to the right or left of the median line. It is sudden and intense 
pain attended by more or less collapse. It may be attended by all the 
symptoms of internal hemorrhage. It may cause vomiting. The history 
of cessation of menses, of discharge of decidua, or other signs of preg- 
nancy, with the local signs on physical examination, indicate the true 
nature of the pain. 

Pancreatic Pain. In disease of the pancreas, either from the passage 
of calculi (extremely rare) or because of pancreatic hemorrhage, there 
may be sudden severe pain. The pain is localized to the region below 
the sternum. It may be severe in the back and extend up the thorax. 
It occurs in paroxysms, and is attended by great anxiety and collapse. 

Gastric Pain. Intestinal colic must be differentiated from pain of 
gastric ulcer, gastric cancer, and gastralgia. The characteristics of pain 
in these affections will be discussed subsequently. When perforation 
occurs in gastric ulcer the pain is usually seated in the epigastrium, but 
may be complained of in the back as high as the mid-scapular region. It 
is sudden and severe, preceded by a history of ulcer and attended by col- 
lapse. There are no evidences of indigestion. Perforation of the biliary 
passages is attended by pain in the hepatic region. The pain is sudden 
and is usually preceded by symptoms due to deraugement of the biliary 
passages, by obstruction of gall-stones. Pronounced collapse follows its 
occurrence. 

Appendicitis. Intestinal colic must not be confounded, although it fre- 
quently has been, with the pains that attend appendicitis. This is par- 
ticularly the case with relapsing appendicitis. In this form only mild 
fever attends the attack. The patient is seized with severe pain, which 
may be described as occurring in the lower right quadrant, but is some- 
times complained of about the umbilicus. It frequently follows indis- 



528 



SPECIAL DIAGNOSIS. 



cretion in diet, and may be attended by vomiting, and is likewise 
usually relieved by eructation, but not by the passage of gas, a point of 
great importance in the diagnosis. The attack occurs mostly in young 
subjects and continues but twelve to twenty-four hours. It may be so 
severe as to cause collapse. If fever attends it, and there is true appendi- 
citis, the diagnosis is much easier. In the relapsing as well as the true 
form there is tenderness at McBurney's point. (See Appendicitis.) 

Peritonitis. Intestinal colic must not be confounded with peritonitis, 
which follows in all the above conditions, or develops at various points in 
the abdomen. The purulent peritonitis that succeeds pyosalpinx may 
be attended by severe pain without much reaction. The pain, however, 
although complained of about the umbilicus, can be localized by pres- 
sure in the lower quadrants and in the pelvis. It may disappear after 
eight or ten hours, to be followed by a recurrence. The recurrence of 
pain is usually attended by fever. In the first twenty-four hours the 
bowels are loose, or at least readily moved. If the peritonitis con- 
tinues it is impossible to move the bowels often. 

Organic Disease of the Bowels. Intestinal colic must not be con- 
founded with organic disease of the bowels on account of which obstruc- 
tion arises. In these affections there is sudden constipation, and rapid 
prostration. The vomiting, if present, persists and soon becomes sterco- 
raceous. In intussusception the stools are characteristic. Strangulation 
or ileus is associated w T ith the presence or history of previous peritonitis 
or hernia. In the latter there may be signs at the hernial points. In the 
obstruction from external pressure the presence of tumors has been known 
previously or can be recognized. In fsecal obstruction, or the obstruction 
by gall-stones, the local signs may be pronounced, and the pain is usually 
in the ileo-csecal region. The above-mentioned source of pain, which 
may be confounded with intestinal colic, usually occurs suddenly. The 
affection is acute. Pain that extends over a long period of time, that 
is not due to an acute process, or attended by severe acute symptoms, 
has been considered elsewhere (see Abdomen). 

Abdominal Rheumatism and Neuralgia. Intestinal colic may be 
mistaken for rheumatism of the abdominal walls. In the latter there 
may be a history of exposure. The muscles are extremely tender. 
There are no gastro-intestinal symptoms, the urine is loaded with uric 
acid and urates, and there may be muscular pain in other situations, or 
a pronounced history of previous attacks of rheumatism. In lumbo- 
abdominal neuralgia the pain may simulate intestinal colic. Pressure- 
points where the respective nerves exit through the fascia are detected. 
Just here may be considered the pain about the navel, which occurs in 
paroxysms, due to disease of the vertebrae. There may be caries from 
tuberculous disease, or from pressure of an aneurism. Examination of 
the vertebrae may determine its nature. 

Fever. The occurrence of fever points to inflammation in some por- 
tion of the gastro-intestinal tract or the abdomen in the diagnosis of 
intestinal colic ; moreover, in the former the pain is constant, but local- 
ized and aggravated by pressure. The skin is hot and dry. 

Diarrhoea. Diarrhoea is a symptom of disorder of the intestine 
which in turn is itself the cause of symptoms, just as jaundice, a 



STOMACH, INTESTINES, AND PERITONEUM. 529 

symptom of hepatic disorder, is the cause of various symptoms. In 
diarrhoea there is increased frequency of the movements of the bowels. 
This is due to increased peristalsis of the intestine, which occurs from 
a number of causes. Not all increased peristalsis results in diarrhoea. 
(A) Increased peristalsis may be due to some impression upon the 
nervous mechanism of the intestine. This may explain the diarrhoea 
of emotion, or that which occurs from other psychical influences. {B) 
On the other hand, in the larger number of cases the diarrhoea is due 
to catarrhal inflammation of the intestinal tract. The causes of the 
catarrhal inflammation are many, and have been divided into primary 
and secondary causes. Primary catarrh is due to the direct influence 
of causal factors upon the mucous membrane. (1) It is seen after cold 
or exposure; (2) it occurs from the direct action of an irritant, as 
undigested food, and (3) from the action of irritants, as of bacteria 
or the products of bacteria. Catarrhal inflammation due to micro- 
organisms is the most frequent form that occurs in children. The 
secondary catarrhs occur with the lesions of more pronounced degree 
which belong to the causes. The catarrh, and hence the diarrhoea, that 
attends the ulceration of typhoid fever, the ulceration of dysentery, or 
that occurs in Bright's disease, and the diarrhoea that attends carcinoma 
or other organic disease of the bowel, is of this nature. In addition 
a catarrh of the bowels arises from venous stasis in the mucous mem- 
brane, with chronic congestion. This occurs in the course of organic 
heart disease or in disease of the liver with portal congestion. 

Diarrhoea is a symptom of certain poisons, such as mercury, arsenic, 
and other corrosive agents. According to Brunton and others, the 
diarrhoea which occurs from the irritant action of food products and in 
cholera infantum is due to a toxic ptomaine. 

Diarrhoea sometimes fulfils a vicarious office. This is the case with 
the diarrhoea which comes on in cases of chronic Bright's disease and 
in acute Bright's disease before the supervention of ursemia. When 
diarrhoea occurs in a person with pallor, dimness of vision, and oedema, 
the urine should always be examined. 

The Symptoms of Diarrhoea. Increased movements of the bowels. 
The frequency of the movements varies with the cause. In the diar- 
rhoea of nervous origin, usually after five or six movements have 
occurred, the patient is relieved because the cause for the nervousness 
has disappeared. In catarrhal diarrhoea the number varies from half 
a dozen in twenty-four hours to the same number in an hour. Indeed, 
in some severe cases the evacuation may be almost constant. 

Abnormal character of the movements. The movements may be 
(1) fcecal, with a small amount of water. They are light in color, 
softer than natural, but yet retain their form. They are the kind of 
movements seen in simple catarrh. 

2. The fseeal matter is mixed with undigested food. The fseces are 
in scybalous masses, and the watery element is increased. They are 
the stools of the so-called dyspeptic diarrhoea. 

3. Along with the fseces mucus in more or less degree is seen. The 
amount of mucus depends upon the seat of the inflammation as well as 
the intensity. Inflammations of the large intestine are attended with 

34 



530 



SPECIAL DIAGNOSIS. 



mucous discharge. The mucus is uot difficult to recoguize. It may be 
mixed with and stained by faeces so that only by close inspection is it 
recognized. In milder degrees of catarrh it is seen on the surface 
of the faecal masses. 

4. The faeces disappear almost entirely, and instead the evacuations 
are watery. The watery evacuations may be discolored, as in the pea- 
soup evacuations of typhoid fever, or they may be almost clear water, 
as in the rice-water discharges of cholera. 

5. The evacuations may contain blood. Bloody discharge usually 
accompanies mucus ; when the catarrh is in the lower bowel it may 
occur independently of the mucus. If with the mucus, it tinges it in 
reddish specks, or small amounts of free blood are seen. The blood 
may be bright in color, and then usually comes from the rectum. The 
source of the blood may be, it must be remembered, from hemorrhoids, 
or fissure, which is unduly irritated by the diarrhoea. It is then 
bright red and unmixed with the movement, and from its position can 
readily be seen to have followed it. If mixed with the movement the 
blood may be black, as in all forms of melcena, or it may be dark red 
in color. The black blood usually comes from the small intestine, or 
stomach, and may be the result of ulceration in the stomach or even the 
swallowing of blood. On the other hand, it may be due to cirrhosis 
of the liver, with venous congestion. It may be due to the ulceration 
of typhoid fever and the intense inflammation of enteritis. It is a 
symptom of carcinoma of the bowel and is of frequent occurrence, 
almost pathognomonic in intussusception. It must be remembered that 
blood of this character is discharged from the bowel independently of 
diseases of that tube, as in purpura, scurvy and other blood diseases. 
(See Arteries of the Intestine, page 525.) 

Microscopical and Bacteriological Examination. In simple catarrhal 
inflammation of the tubules, on microscopical examination but little is 
found except an excess of epithelium from the mucous lining. In 
more intense inflammations, in addition to epithelium there are pus 
and blood and mucus. Micro-organisms are found dependent upon the 
cause of the diarrhoea. In health Booker has found at least forty 
varieties of micro-organisms, many of which, in all probability, are not 
pathogenic. In health the bacillus coli communis and the bacterium lactis 
aeriformis are found. In the diarrhoea of children both forms are present 
in excessive numbers, because conditions favoring their growth arise, and 
in all probability are the cause of the irritation of the bowel. In that 
form of inflammation of the bowel known as dysentery, in addition to 
the bacteria that attend inflammations, the amoeba coli is present. It 
has been found that dysentery may be due to a number of causes, but 
that the so-called tropical dysentery is due to the protozoa first described 
by Kartulis and in this country by Osier. (See Faeces.) 

The symptoms that attend increased movement of the bowels depend 
upon the cause and also have direct relationship to the frequency of the 
evacuation. The symptoms most frequent are pain, flatulent distention, 
with borborygmi and tenesmus. Pain. The pain depends largely 
upon the cause. If the irritant is a product of indigestion, or a bulky 
mass, pain is more or less severe. It is situated in the centre of the 



STOMACH, INTESTINES, AND PERITONEUM. 



531 



abdomen, and may extend all over. It occurs before the evacuation ; it 
is sharp, lancinating, and is usually relieved by the movement. If the 
inflammation is in the large intestine the pain may be complained of in 
the course of the large bowel or be more intense over the caecum and 
the sigmoid flexure. The rectum may be the seat of pain or of painful 
sensations. This has been described as a feeling of a hot ball in the 
lower pelvis. Flatulent Distention. The flatulent distention is not very 
great generally. The abdomen is distended, tympanitic on percussion, 
and tender on palpation, both of which may be more marked in the 
middle of the abdomen if enteritis alone is present, or it may extend 
along the course of the colon, as in the so-called entero-colitis of chil- 
dren. With the distention there are borborygmi. The rumbling usually 
subsides after the evacuation. 

Tenesmus occurs in all forms of diarrhoea if the evacuations have 
been frequent. After the discharge of the contents of the bowel, par- 
ticularly if from the rectum, the tenesmus is much more severe, and 
may be of constant occurrence. In the severe cases the tenesmus may 
be almost continual. On account of it prolapse of the bowel is liable 
to ensue. 

General Symptoms. The general symptoms that attend diarrhoea 
depend upon the cause. In simple diarrhoea there may be slight fever- 
ish ness only, with a little weakness. In diarrhoea, with excessive 
movements, with mucus, with or without blood, the fever is marked 
and may rise as high as 103°. The fever that attends dysentery is high, 
and usually rises rapidly at the beginning. 

Prostration. More or less prostration attends all cases. It is, how- 
ever, more marked when there are frequent watery evacuations. In its 
most pronounced degree it is seen in cholera and cholera infantum. 
Collapse rapidly ensues under these circumstances on account of the 
depleting effects of the excessive watery discharge. In catarrh of the 
intestines secondary to typhoid fever and other conditions the general 
symptoms depend upon the primary disease. 

Chronic Diarrhcea. Chronic diarrhoea may be due to chronic 
inflammation of the bowels, as in chronic intestinal catarrh. It may be 
secondary to the ulceration of dysentery, tuberculosis, syphilis, or cancer. 
It is the common diarrhoea of amyloid disease. In chronic diarrhoea the 
stools vary, but seldom amount to more than ten to fifteen in a day. In 
chronic intestinal catarrh three or four movements occur in the twenty- 
four hours. They usually occur in the morning, the first evacuation taking 
place immediately on rising and the remainder during the morning 
hours. They are more common in women than in men, and are readily 
excited by exhaustion or nervous influence, as grief, emotion, or excite- 
ment of any kind. The stools are faecal and watery and contain some 
mucus. The mucus usually coats the surface of the faeces. The color 
of the faeces is not changed. The patients usually suffer from the 
symptoms of intestinal dyspepsia or are subject to some gastric neur- 
osis. They are not under weight, and except for the inconvenience of 
the morning hours could attend to the ordinary demands of life. They 
are more nervous than most people, and are liable to attacks of hemi- 
crania. 



532 



SPECIAL DIAGNOSIS. 



Membranous Diarrhcea. In a number of cases the discharge 
from the bowels resembles membrane. The disease is also called mem- 
branous enteritis. The discharges contain much mucus, and may be 
a little more watery. After the fasces have been passed membrane 
is discharged. This may be in shreds or large masses, and may also 
be like a cast of the bowel. The patients are usually females who 
are hysterical and have some menstrual disorder. Pain may precede 
the discharge, and continue until there is complete relief. 

Constipation. Constipation may be due to a number of causes. It 
may be due to alteration or diminution in the secretions of the intestinal 
tract, as is seen in all fevers, except when they are attended by specific 
intestinal catarrh, as in typhoid fever. Such diminution of secretion 
occurs in the summer, when there is more free perspiration than in 
other seasons, and is present in affections attended by excess of perspira- 
tion, or exhaustive diuresis. Constipation, therefore, is a common 
symptom of diabetes. 

In addition to alteration of the secretion, diminution in the sensibility 
of the nerves may exist. This is the one chief cause of habitual consti- 
pation that is so prevalent. On account of carelessness the patient loses 
the habit of having a regular movement of the bowel each day, and in 
consequence the usual stimulus is removed. Constipation also occurs 
from weakness of the muscles. 

The three conditions, diminution or alteration in the secretions, de- 
bility of the muscles, and impairment of the sensibility of the nervous 
mechanism, are combined influences on account of which constipation 
is so prevalent in persons of sedentary habits and in persons living 
upon improper diet. General diseases and local disorders which influ- 
ence either of the above elements cause constipation. Thus in anaemia 
and chlorosis, in neurasthenia and hysteria, constipation is a common 
condition. Its occurrence in fevers has been mentioned. In the con- 
valescence from exhausting disease and prolonged confinement to bed 
constipation is liable to ensue. 

Local Causes. Atony of the abdominal muscles or of the bowel is 
the cause. Atony is most strikingly seen in peritonitis and typhlitis, 
in both of which a paretic state of the bowel develops. It is seen in 
the aged and in cachexia along with atony of other muscles. Obstruc- 
tion of the bowels, acute or chronic, causes constipation usually (q. v.). 
If the obstruction is not complete there may be, on account of catarrhal 
inflammation, diarrhoea. Constipation often occurs on account of pain, 
seated in the rectum particularly. The pain is such that the patient 
shrinks from an evacuation. Frequent postponement soon causes con- 
stipation. The pain may be due to fissures, to hemorrhoids, or to 
fistula. Constipation occurs also from local diseases in other portions 
of the body influencing, in all probability, the nervous mechanism by 
which peristaltic action is excited. In acute and chronic disease of the 
brain and cord, as meningitis and myelitis, constipation is a chronic 
attendant. It also occurs in tetanus. If the bowel is deprived of fsecal 
matter evacuations of the bowels cease. Constipation is a constant sign 
of stricture of the pylorus and of stricture or cancer of the oesophagus. 

Symptoms of Constipation. Constipation is characterized by diminu- 



STOMACH, INTESTINES, AND PERITONEUM. 533 

tion in the frequency of the bowel movements. The frequency of the 
movements varies in health. Some persons are comfortable with an 
evacuation taking place once a week, or at least every third or fourth 
day. There are cases on record in which the evacuations took place 
but once a month. Cases of this class are usually due to muscular 
paralysis of the bowel, with secondary dilatation. The accumulation 
of faeces is removed by a sharp attack of diarrhoea, attended by much 
pain. The diarrhoea sometimes continues for twenty-four hours. When 
it sets in fever may be present until there is thorough evacuation. 

Local Symptoms. Usually the symptoms that attend constipation are 
local on account of the discomfort of the accumulation of faeces. The 
local symptoms may be limited to the rectum or extend through the 
abdomen. In the rectum there is a sensation of a mass, which may cause 
some pain. The abdomen is distended ; there is considerable rumbling, 
and sometimes peristaltic waves are seen. The accumulation of the faecal 
mass in the bowel may set up tormina and tenesmus, and portions of the 
masses may be discharged from time to time. In other words, a diarrhoea 
may occur, the diarrhoea of constipation, or spurious diarrhoea. The 
stools are small, composed of hard scybalous masses, generally coated 
with mucus, and with some blood. The evacuation does not give relief, 
and the desire for a movement may be more or less continuous. 

On examination in constipation with faecal accumulations the outline 
of the colon may be marked out by palpation and percussion of the 
distended abdomen. In its course masses are felt varying in size from 
a marble to a base ball, and in consistence they may be soft to the pal- 
pating finger ; they are never indurated like a calcareous mass, as gall- 
stones or a mass due to malignant disease. 

General Symptoms. While in many instances the general symptoms 
are of no consequence, in others the patients are nervous and may be in 
more or less impaired health on account of the secondary effects upon 
the stomach. Digestion is impaired and the form of indigestion is that 
which attends neurasthenia. 

The patients are of spare habit, usually of dark or muddy com- 
plexion. They may be depressed. There is inaptitude for mental 
exertion ; they are more or less hypochondriacal. The tongue is con- 
stantly furred, the appetite variable ; there is weight and fulness after 
eating, and generally some flatulency. 

The Secondary Effects of Constipation. The effects of constipation 
upon the intestines is various and sometimes disastrous. They are dila- 
tation and ulceration. The former may become enormous, as in cases 
reported by Formad and Osier. The dilatation may be so great as to 
distend the entire abdomen. The ulceration may be localized to the 
rectum, or C83cum, or extend throughout the entire large intestine. On 
palpation the course of the colon is tender, and fsecal masses may be 
outlined and may be painful because of their pressure upon the ad- 
jacent ulcer. In the rectum the ulcer may be deep, and be followed 
by peri-rectal abscess. 

In the caecum the accumulation may be such as to cause a large boggy 
swelling, extending in the course of the caecum, which is tender on pres- 
sure, and dull on percussion. Stercoral typhlitis is caused (q. v.). 



534 



SPECIAL DIAGNOSIS. 



Faecal impaction, with secondary ulceration, is of frequent occurrence 
in typhoid fever. This must be borne in mind, for often serious gen- 
eral and local symptoms arise because it is overlooked. Recently I saw 
a case with the diarrhoea of constipation, with some fever, which per- 
sisted for weeks after the usual course of typhoid fever. It was thought 
the patient had tuberculosis, or that the typhoid process was abnormally 
prolonged. Examination disclosed ulceration into the vagina, and the 
faeces were constantly discharged from this orifice. It had been thought 
that the discharges of faeces were due to diarrhoea. Of course, fever 
attended the process, and rendered the case all the more obscure. 

In this connection must be mentioned the constipation that occurs on 
account of lead-poisoning, and the exhibition of drugs, as opium, or 
astringents. The constipation of lead-poisoning is usually attended by 
colic, and the blue line on the gums is seen, while wrist-drop or other 
manifestation of lead may be present. 

Intestinal Hemorrhage. 

The causes are general and local. The general causes are those that 
accompany hemorrhage in other localities. (See Gastric Hemorrhage.) 
The local causes (1) in which hemorrhage is small, are : inflammation of 
the bowel ; traumatic injury to the bowel from hernia, faeces and parasites, 
and foreign bodies swallowed, or from corrosive poison ; tumors of the 
bowel ; as in cancer, invagination, and ulcers. (2) Large hemorrhage 
occurs in the congestion attending portal obstruction and liver disease, or 
disease of the heart with secondary obstruction. Aneurism of the superior 
mesenteric artery, or aneurism rupturing into the intestine, and occasion- 
ally embolism of the artery will be followed by intestinal hemorrhage. It 
occurs in ulcers first from typhoid fever ; second, from dysentery ; third, 
from syphilis. It may occur in pyaemia and septicaemia, or the acute 
exauthematous diseases. The symptoms may be those of hemorrhage 
alone : collapse, pallor, failure of sight, tinnitus, vertigo, small pulse, 
and general restlessness. The hemorrhage must be copious under these 
circumstances, and is due (1) to the bleeding of an ulcer, as in typhoid 
fever ; (2) to portal obstruction ; (3) to an aneurism ; (4) to purpura or 
haemophilia. 

A second group of symptoms referred to the appearance of the dis- 
charges from the bowels. The stools are bloody ; if the hemorrhage is 
low down they are bright red and usually mixed with faeces. If high 
up, they are tarry. They are known as melaena (see Faeces). 

The passage of the stools is preceded by colicky pains, or there may be 
some rumbling. The diagnosis must be directed toward determining 
the cause of the hemorrhage, as well as its seat; the history, the associate 
diseases, or symptoms, aid in determining the cause. Examination of 
the rectum may afford a clue to its origin. 

The Data Obtained by Observation. The Objective Symptoms. 

Physical Signs. Inspection. Local and general enlargements of 
the abdomen have been discussed in the preceding pages. Movements 



STOMACH, INTESTINES, AND PERITONEUM. 



535 



of the intestines are seen in obstruction due to increased peristalsis. 
The intestine above the point of obstruction may swell into a defined 
tumor which becomes hard and dull, tympanitic on percussion. 

Palpation. Tenderness, peristalsis, peritoneal frictiou, the bubbling 
of gas through a constriction of the bowel, and tumors, are recognized 
by palpation. It is necessary often to place the patient on all fours or 
in a knee-chest position. 

Percussion. The normal note is tympanitic. Local areas of dulness 
may be due to intestinal tumor. Light percussion should be employed. 
A dull tympany indicates a solid mass surrounded by the distended 
intestines. The outline of the large intestine can be ascertained by 
filling it with water. 

The Faeces. General Considerations and Macroscopical 
Appearances. The number of stools varies chiefly in health with 
the individual and the character of the food taken. After infancy, 
one passage in twenty-four hours is the rule, but it is natural for 
some persons to have two or three, and for others to have but one 
passage in two, three, or four days. Such a condition is termed 
constipation, while pathological constipation is properly called obsti- 
pation. The opposite condition is known as diarrhoea. The amount 
and character of food and drink ingested influences the number of 
the stools. Exercise also plays a role ; and increased or diminished 
peristalsis, from whatever cause, will induce on the one hand diarrhoea, 
and ou the other constipation. In disease the greatest extremes are met 
with — from the non-passage of faeces for days, as in obstruction, to an 
almost continuous discharge, as in some forms of intestinal inflamma- 
tion. It is well to remember that diarrhoea may be the symptom of 
obstipation, as when impacted faeces in typhoid cause looseness of the 
bowels. 

The amount of faeces varies with the quantity and nature of food. If 
most of the food is digested and carried away for the economy, there 
will be but little left to form fseces. In any disease that prevents the 
absorption of digested food, or causes an increase in the fluid contents of 
the intestine, as cholera, the amount of faeces will be increased. In 
health about 140 to 200 grammes are voided in twenty-four hours. 

The form and consistence of healthy stools varies somewhat. They 
are commonly cylindrical and firm or mushy. When they remain long 
in the intestinal canal, and the water is extracted, they become hard and 
may form balls, or flattened masses, known as scybala. These are 
frequently seen in convalescing typhoid patients. On the other hand, 
the faeces may be without form, and are then liquid, either watery as in 
cholera, or purulent or bloody. Many varying diseases cause such a 
condition. 

The odor of faeces is sometimes more or less characteristic of certain 
conditions. Thus the stools of nursing infauts have a sour smell, while 
in infantile diarrhoea and when fermentation takes place they have an 
odor of sebacic acid. When urine is mixed with the passage the odor 
will be ammoniacal ; with blood present it often has a stale odor. 

The reaction is not constant. Thus in intestinal catarrh, with acid 



536 



SPECIAL DIAGNOSIS. 



fermentation it will be acid, or in alkaline fermentation it will be alka- 
line. 

The color of the stools varies too much to be of special diagnostic 
value. In health it is light to dark brown, due chiefly to the presence of 
hydro-bilirubin, a product of decomposition of bile pigment which is 
never normally found unaltered in the faeces. It is influenced greatly 
by food and medicines. When certain berries, as huckleberries, are 
eaten, or certain medicines taken — iron and bismuth — they make the 
passages black. Calomel causes green stools, by causing biliverdin to be 
present. Green stools may also receive their color from the presence of 
a bacillus which produces a green dye. Santonin, rhubarb, and senna, 
cause yellow; and haematoxylon, red stools. The last fact is important, 
as parents or nurse should always be instructed, when haematoxylon is 
given, to expect red passages. 

The faeces may be red or reddish from the presence of unaltered 
blood, or black when the blood has undergone changes ; the so-called 
"tarry stools" are of this character. With a decrease in the amount 
of bile the stools become less colored, and if the bile is cut off they 
become clayey. This color may in cases be due to the presence of fat 
left undigested because of the lack of bile. On the other hand, if from 
disorders of the stomach and intestine the intestinal contents pass too 
rapidly through the intestine, the faeces may contain unaltered bile or 
unchanged bile pigment, giving a green or yellow color, and showing 
the bile reaction. 

The constituents of fceces that can be recognized by the naked eye are 
numerous. Seeds, stones, and skins of fruit and berries ; fibres of vege- 
tables, are often seen in healthy stools. In the passages of children and 
weak-minded individuals may be present foreign substances of all 
descriptions. Foreign bodies and partially digested portions of food may 
be mistaken for parasites. Portions of tumors from the digestive tract 
may appear in the faeces. 

In certain diseases of the stomach and small intestines, and in those 
who eat very fast and do not properly masticate their food, undigested 
and unchanged particles of food may be seen in the stools. 

Shreds of mucous membrane of varying size are passed with the faeces, 
or constitute them, in cases of membranous enteritis. Von Jaksch saw 
such a shred 5 cm. long and 3 cm. broad in a case of cholelithiasis. 

Particles resembling sago-grains, perhaps the result of over-indulgence 
in farinaceous food, have been met with. 

Gall-stones in the faeces have great clinical value. They may escape 
detection, if not properly sought for. W r hen suspected, each passage 
should be passed through a linen sieve, the faecal masses being softened 
with water. They may be found as small, crumbling masses, composed 
chiefly of cholesterin (intra-hepatic calculi), or as hard, irregular, 
smoothly-worn, shining, many-sided, hard stones, sometimes as large as 
an egg ; usually the size of a pea. Enteroliths are occasionally seen. 
They are said to originate in the appendix. 

Blood may be present in the faeces in varying proportions and condi- 
tions. When found unaltered on the surface of scybalous masses it is 
from the rectum or large intestines, and probably the result of trauma- 



STOMACH, INTESTINES AND PERITONEUM. 



537 



matism. Hemorrhoids, if bleeding, may cause such an appearance, or 
may cause very free hemorrhage. Severe hemorrhage may come from 
ulceration of the rectum or colon, due to malignant disease or severe 
inflammation. The blood may be intimately mixed with the fseces, and 
have its origin in the large intestine, but much more commonly it indi- 
cates a source in the stomach or small intestine. Under such circum- 
stances it is nearly always more or less changed by the intestinal juices, 
and is brownish-red or black, the tarry stool as mentioned above, or has 
the appearance of coffee grounds. The more retarded the passage the 
greater the change; while, if quickly expelled, blood from the small 
intestine may be passed unchanged, as in the hemorrhage of typhoid 
fever. The microscope detects blood when the naked eye fails to detect 
it. It is to be remembered that certain drugs, as already stated, may 
color the faeces red, and simulate blood. 

Mums may be present in the passages in health, but when in any 
marked quantity there is a catarrh of the mucous membrane of the intes- 
tines. When hard scybala are covered with mucus, or the mucus is 
seen as shreds, the large intestine is the seat of a catarrh, though it may 
be mixed with thin stools, as in dysentery. But usually when the mucus 
is finely divided and mixed with the feces, it comes from the small 
intestine. Mucus shreds have already been mentioned. In cholera 
the particles of mucus look like boiled rice, hence the term " rice-water 
stool." 

Fatty stools, to the naked eye, appear greasy or even clayey, when 
there is much fat, even though bile pigment may be present. 

Pus may be present in large quantities from rupture of an abscess 
into the intestinal tract, or when there are ulcerations from various 
conditions, producing pus in considerable quantities. 

Many animal parasites are visible to the naked eye, but a full con- 
sideration of them will be given in the following paragraphs. 

Microscopical Examination of the F^ces. A small portion 
of the solid fseces to be examined is placed on a slide moistened with 
water and J per cent, salt solution, and a cover-slip applied ; or if liquid, 
various drops are to be examined. The differeut constituents to be found 
will vary with the food taken as well as with disease. 

Constituents Derived from Food. There may be portions of 
digested or undigested food. In general it may be said that the presence of 
large pieces of unchanged food or many small particles of undigested or 
only partially digested food, indicates defective digestion in the stomach 
or small intestine. If unchanged bile is present, then particles will be 
colored yellow, another indication of diseased functions. 

From the food we may see muscle and elastic fibres, more or less as 
the quantity of meat the patient eats varies. The former are recognized by 
their transverse striation ; the latter, by their double contour and cur- 
ling ends. Fat may be present as fatty globules or in the form of needles, 
fatty crystals. Much fatty food increases their number, and they are 
seen plentifully in alcoholic poisoning, in jaundice, in the fatty pancre- 
atic diseases, tuberculosis of intestines, diseases of the mesenteric glands, 
and enteritis. The crystals may be transformed into fat-drops by the 
addition of acid and heat. When meat is eaten freely, areolar tissue 



538 



SPECIAL DIAGNOSIS. 



may be present, but its presence otherwise points to defective digestion. 
Various forms of vegetable cells are commonly seen, in which granules 
of starch may be contained, or the starch particles may be free. Un- 
digested milk occurs in the stools of children and when diarrhoea pre- 
vails ; a substance, probably cercin, has been described by Nothnagel 
as occurring in faeces of persons who have intestinal disturbances. 

In persons living on vegetables, the majority of the above constituents 
will be absent, and in infants who partake only of milk, the derivates 
of meat are absent, while there will be an excess of fatty crystals and 
fat globules and coagulated products. 



Fig. 81. 




Collective view of the faeces. (Eye-piece III., objective 8A, Reichert ) a. Muscle fibres, b. Con- 
nective tissue, c. Epithelium, d. White blood-corpuscles, e. Spiral cells, f-i. Various vegetable 
cells, k. Triple phosphate crystals in a mass of various micro-organisms. I. Diatoms. (Von 
Jaksch.) 

Constituents from the Alimentary Tract. Epithelium. In 
every normal stool will be found epithelium of the squamous variety. 
Occasionally the columnar form is seen, and altered epithelial cells are 
very common. In intestinal catarrh their number is greatly increased. 

Red Blood-corpuscles. In the majority of blood-stained stools red 
blood-cells are not found ; in their stead will be seen masses of free 
blood-coloring matter and rhombic crystals of haematoidin. Red cells 
are seen in dysenteries, in bloody stools in which the blood comes from 
near the anus, as in hemorrhoids, and when a hemorrhage is discharged 
with the faeces soon after its occurrence. If there is any doubt as to 
the presence of blood when the corpuscle cannot be found, a true 
decision can be reached by examining for hgeniin crystals, according to 
Teichmann's method. A portion of faeces is dried and powdered, 
placed on a slide with a grain of common salt, and covered by a cover- 
slip. A few drops of glacial acetic acid are directed beneath the slip, 
the slide is heated just to boiling, and if blood has been present, reddish- 
brown rhombic crystals of haemin will soon be found. 

Leucocytes. These oodies are frequently seen in healthy stools. 
When pus is found in or discharged into the intestinal canal, they are 
found in great numbers, as in ulceration of the intestine and in abscess. 

Molecular debris, or detritus, occurs in all faeces as part of the 
waste products. 



STOMACH, INTESTINES, AND PERITONEUM. 



539 



Crystals. Fat crystals are the most important. They have been 
quite fully considered above. There seems to be but little doubt that 
the crystalline needles found in the faeces are salts of fatty acids, and 
not tyrosin. 

Charcot-Leyden crystals, similar to those already described uuder 
sputum, have occasionally been met with in the stools of typhoid fever 
patients, in dysentery, intestinal tuberculosis, and ankylostomiasis. 

Hcematoidin crystals occur as reddish-brown, hard, needle-shaped 
bodies, usually in clusters, and free or enclosed in masses of mucin or a 
substance resembling it. They have been found in the faeces of breast- 
fed infants ; in cases of chronic intestinal catarrh, and by Von Jaksch in 
the stools of a case of nephritis. 

Crystals of various salts of calcium, of triple phosphate and cholesterin 
will often be recoguized, but they have no diagnostic value. When 
bismuth is being administered black rhombic crystals of the sulphide of 
bismuth will be recognized. 

Parasites. {A) Animal, and (B) vegetable parasites flourish in the 
intestinal tract, and the presence of some of these in the faeces is of the 
greatest clinical importance. 

A. Animal Parasites. Following Leuckart's classification, we 
will consider these parasites under the secondary heads : 

I. Protozoa. 1. Rhizopoda. This variety is made important be- 
cause the amoeba dysenteriae or amoeba coli belongs to it. 

(a) Amoeba Dysenteric. Amoeba Coli. This protozoon has been 
found so many times by various observers in different parts of the 
world that it can now be considered to be the causative factor of so-called 
tropical dysentery. The subject has received special study in our own 
country by Osier, 1 Stengel, 2 Dock, 3 andCouncilman and Lafleur. 4 The 
unexcelled work of Councilman and Lafleur is at the present time the 
best that has been published in any country ; and to it the reader is 
particularly referred. The following notes are based on this book. 

The amoebae dysenteriae vary in size from 0.012-0.035 mm. They 
are found most plentifully in the small gelatinous masses often to be 
seen in the faeces. They vary in number in different cases and in the 
same case at different times. The severer the lesions the more numerous 
are the amoebae. When not active they are round or oblong, and highly 
refractive. They contain one or more vacuoles of varying size. Occa- 
sionally the division into an ecto- and endosarc is easily made out. 
When thus inactive, they may be confused with swollen connective- 
tissue cells and compound granular bodies found in faeces. The active 
amoebae have, however, a characteristic movement. This consists of 
progression and of thrusting-out and retraction of pseudopodia. Their 
activity varies greatly. It is best seen when the body heat is maintained. 
The stools should be passed into a clean and warm pan, and examined 
immediately, or kept warm until examined, and a warm stage should 
be used with the microscope. The division into ecto- and endosarc is 

1 Johns-Hopkins Hospital Bulletin, May, 1890, vol. i., No. 5. 

2 Phila. Med. News, 1890. 

3 Texas Med. Journal, April, 1891. 

4 Johns-Hopkins Hospital Reports, vol. ii., Nos. 7, 8, 9. 



540 



SPECIAL DIAGNOSIS. 



usually clear during activity. The ectosarc is composed of a hyaline 
homogeneous mass, as are the pseudopodia, while the endosarc is made 
up, not of granular matter, but of a dense homogeneous matter enclos- 
ing vacuoles and a nucleus. The vacuoles may vary in size as well as 
in number. There may be one or two large ones, or the entire endosarc 
may appear as made up entirely of small vacuoles. The nucleus is 
sometimes plainly seen as a small rounded body, but is more often diffi- 
cult to distinguish from the vacuoles. Dried cover-slip preparations 
may be stained with the various aniline dyes, but the results are not 
satisfactory. 

The amoebae will often be found to enclose bodies such as red blood- 
corpuscles, pus cells, blood-coloring matter, bacilli and micrococci. 

In examining the faeces for amoebae dysenteric the suggestion given 
above concerning the warm bed-pan and warm stage to the microscope, 



Fig. 82. 




Amoebae coli. (Hallopeau.) 



and above all, the immediate examination of the stool, should be adhered 
to. The small gelatinous masses should be selected when present. 
Various magnifying powers should be used, including the ^-immersion 
lens. 

(b) Monadines, pear-shaped, with a long slender process, are seen 
alive only in perfectly fresh stools. They are not found constantly in 
any one disease. 

2. Sporozoa. Under this head belongs the coccidium perforans of 
Leuckart. They are short, elliptical bodies, which infest the intestinal 
mucous membrane, and may damage it badly ; they are often discharged 
in large numbers. 

3. Infusoria, (a) Cercomonas intestinalis. This is a pear-shaped 
body, nucleated, with eight tentacles of varying length. It is found in 
the faeces of persons suffering from various diseases, as cholera and 
typhoid fever, and probably of itself causes diarrhoea. 

(b) Trichomonas intestinalis. Larger than the cercomonas, and cov- 
ered with ciliae at the club end. It is not diagnostic, and is not common. 

(c) Paramecium coli. Larger than the preceding, 1 mm. long — 
oval, covered everywhere with ciliae; may be found in diarrhoeic stools. 



STOMACH, INTESTINES, AND PERITONEUM. 541 



II. Vermes. These are much more generally known and are of 
much more clinical value than the preceding. 

They have important clinical value, as the presence of some of them 
in the intestinal canal gives rise to many untoward symptoms. They 
will be considered under (A) Platodes. (B) Annelides. 

A. Platodes. 1. Tape-worm — Cestodes. These parasites infest the 
small intestine only, to the walls of which they cling by the head. The 
head and neck are small ; the joints are flat and form long ribbons. 
The distal joints continually drop off and can easily be recognized in 
the stools by the naked eye, and the eggs by the use of the microscope. 
The faeces are best washed in water and broken up to obtain the eggs. 
As the lower joints are lost new ones take their place from above. The 
more important are as follows : 

a. Taenia solium (Fig. 83.) reaches a length of two to three metres. 
The head is the size of a pin-head. The neck is 2.5 cm. long, as thick 
as a thread, and without joints. The segments forming the body are 



Fig. 83. Fig. 84. 




Head of T. solium, x 45. (Leuckart.) brown shell is indicated. (Leuckart.) 

short and broad near the neck, but as they increase in size there is more 
growth in length than in width. The average dimensions are 9 to 10 
mm. X 6 or 7 mm. The head appears dark, the body white. The 
joints are easily detected in the faeces by the naked eye. Under the 
microscope the head is seen to be spheroid, with four pigmented suck- 
ing discs surrounding at the base a rostellum, which is a u crown of 
hooks' 7 — chitin hooks — about twenty-four in number. In the ripe 
segments, or proglottides, is seen the longitudinal uterus with about 
twelve horizontal ramifications to a segment. The eggs are round or 
oval, 0.035 mm. long, with a thick, striated shell when ripe, and con- 
tain hooklets. 

b. Tarnia mediocanettata, or saginata. This worm is four or five 
metres long. The head is slightly larger than that of the T. solium, 



542 



SPECIAL DIAGNOSIS. 



and more pigmented, and the segments are longer, fatter, and darker. 
The head is supplied with four powerful suckiug cups, but there is no 
rostellum or hooklets. The uterus in the ripe segments is much more 
finely branched than in the solium, and these segments have independent 
movement. The eggs are very similar to those of the T. solium, but 
may be rather larger. 

c. Taenia nana. In length the T. nana is only 10 to 15 mm., and 
0.5 mm. in breadth. The round head is but 0.3 mm. in diameter. The 
segments are all short, and at the lower end of the body are four times 
as wide as they are long. The head is found to have four round suckers 
at the base of a rostellum that can be inverted. At the base of the 
rostellum are about twenty-two hooklets. The uterus is oblong and 
filled with eggs. The eggs have a double membrane. 

d. Tcenia cueumerina. This parasite is found to be 5 to 20 cm. long 
and about 2 mm. wide. The head is placed at the thinner end, and 
under the microscope are to be seen some sixty hooklets distributed 
with order about the rostellum, and four sucking cups. The lower seg- 
ments are decidedly larger than the upper — 6 by 7 mm. When ripe, 
they become reddish, and contain cocoon-like bodies, in which are six to 
twelve eggs. 

e. Bothriocephalus latus. This is the largest of the worms, measuring 
7 or 8 metres. The head is somewhat drawn out, and on either side is 
a long, narrow sucker. There are neither hooks nor rostellum. The 
proglottides are short near the head, but become square further down. 
The uterus appears as a rosette, peculiar to this worm. The eggs are 
oval and measure 7 mm. by 0.045 mm., have a shell covering, with an 
opening like a lid at one end. Ripe segments are thrown off in bunches, 
not singly. 

It will not be necessary to describe certain other varieties that are 
rarely met with. 

2. Trematodes, or flukes, a. Distoma hepaticum measures 28 mm. 
by 10 mm., and is shaped like a leaf. A short head is situated at the 
broad end and has one sucker ; on the under surface is another sucker, 
and between the two is the opening of the uterus, a highly convoluted 
arrangement. The eggs are brown, oval, about 0.12 mm. long, and have 
a lid at one end. It is not often seen. 

b. Distoma lanceolatum. This round-shaped worm is about 8 mm. 
long and 3 mm. broad, and in other respects resembles the preceding. 
The eggs are more rounded and contain minute embryos. Like the D. 
hepaticum, it is rarely seen. 

c. Distoma crassum is the largest — 4 to 8 cm. long. These flukes are 
endemic in parts of Japan. In general these animals occupy the bile- 
passages or upper part of the small intestine. 

B. Annelides. 1. Round worms — nematodes, a. Ascarides. 

a. Ascaris lumbricoides. This is the parasite usually referred to by 
the term round worm. It resembles the common earth-worm in shape 
and color. The male worm is about 250 mm. long and the female 400 mm. 
The head is made up of three prominent lips, and is supplied with 
microscopical teeth. The vulva of the female is in the posterior third 
of the body. The eggs are rounded, brownish, 0.06 mm. in diameter, 



STOMACH, INTESTINES, AND PERITONEUM. 



543 



and covered when fresh by a rough albuminous coat over a hard shell. 
This worm has the small iutestine for its habitat. It may pass with the 
stools or work its way iuto the stomach and be vomited (the writer has 
had them thus vomited during the etherization of a child of ten years). 
They have been the cause of jauudice by crawling into the ductus chole- 
dochus, and may infest the larger hepatic ducts. Enormous numbers 
may be present in the intestine at one time. 

b. Oxyuris vermicularis. The thread- or seat-worm inhabits the large 
intestines, and is often present in the stool as a white, thread-like body ; 
the male 5 mm. and the female 10 mm. long. They often wander out 
of the anus and into the vagina. The head has a number of small lips, 
and is covered with a thick skin. The female has one vagina and two 
uteri. The eggs are unsymmetrical, have a laminated shell, and have a 
diameter of about 4 mm. 

B. Strongylides. Ankylostomum duodenale. This is a round worm, 
reaching a length of 6 to 10 mm. in the male and 10 to 18 mm. in the 
female, and can therefore be seen easily, though the eggs are much more 
frequently found in the stool than is the worm itself. With the eggs 
there may be present in the stools large numbers of Charcot- Leyden 
crystals. The head is prominent, especially in the male. Four hook- 
like teeth surround the mouth, and by these the animal attaches itself 
to the intestinal wall. The tail of the male is expanded and that of the 
female pointed. The vulva is in the posterior third. The eggs are 
oval, about 0.05 mm. in diameter, and contain one to four cells — em- 
bryonic globules, which rapidly develop in a warm place outside the 
body, and may thus be recognized. The worm infests the small intes- 
tine, especially the jejunum. It often causes serious symptoms — bloody 
stools and intense anaemia. 

C. Trichotrachelides. a. Trichocephalus dispar. The whip-worm is 4 
to 5 cm. in length, the female being longer than the male. It is recognized 
by the contrasting form of the anterior and posterior portions. The 
former is thin and threadbare, the latter expanded and broad, and in the 
male curled up. The eggs are brownish, about 0.05 mm. long and 
half as broad, and have a button-like projection at either end ; they 
are to be recognized in the stools, where large ones may be present. 
There may be only a few, or thousands, of the forms present in the body. 
They live chiefly in the caecum and large intestine. They have been 
thought to cause beri-beri by some writers. 

6. Trichina spiralis. It is the adult trichinae which exist in the 
intestine, and are found very infrequently in the faeces. These produce 
the embryos, which become muscle trichinae. The adult male is 1.5 mm. 
long and the female twice that length. The former has two projections 
from the hinder end, between which are four papillae. The female has 
a tubular uterus and a tubular ovary in the posterior half of the body. 

D. Rhabdonema. Strong yloides. Under rhabdonema intestiuale 
we now include two small nematodes, which were termed anguillula 
intestinalis and A. stercoralis, and which are probably one and the 
same. They are found in the stools of cases of endemic diarrhoea of hot 
countries. Usually the young embryos, which have developed in the 
intestinal canal, are rejected with the stools. These sexually mature 



544 



SPECIAL DIAGNOSIS. 



embryos are 0.8 to 1.2 mm. long, male and female respectively. They 
are round and have a cone-shaped head. There are two jaws and two 
teeth in each. The adult worm is about 2.2 mm. long and 0.04 mm. 
thick. The mouth has three lips. The vulva is at the beginning of the 
posterior third. The eggs might be easily confounded with those of 
the ankylostomum duodenale but are somewhat more pointed — larger. 
The rhabdonema infests the small intestine, and is frequently found in 
connection with ankylostoma. 

Ecchinococcus hooklets and portions of the striated cyst wall have 
been found in the fasces. The rupture of an hydatid cyst into the intes- 
tine may have much clinical value when the above structures are found — 
pointing to a cyst in the abdominal cavity. 

B. Vegetable Parasites. We find both (I.) pathogenic and 
(II.) non-pathogenic vegetable parasites in the faeces. The latter we 
have classed as (1) moulds, (2) yeasts, and (3) fission fungi. 

1 . Moulds. The only mould found in the stools is the thrush fungus, 
when children are the subjects of thrush in the mouth. It is of very 
rare occurrence in the faeces and has no special clinical import. 

2. Yeasts. In all faeces, in health or disease, yeast fungi exist. They 
are most numerous in acid stools. They are round or ovoid and 
usually occur in groups. They stain dark brown with a solution of 
iodine and iodide of potash, while apparently similar cells become violet 
or blue with the same dye. 

3. Fission Fungi. Bacteria are found in greatest numbers in the 
faeces, chiefly as bacilli, micrococci and spirilla. They may be grouped 
as torulae or sarcinae. They present active movement and may be sep- 
arate or in colonies. The bacillus coli communis (B. termo) is the 
most frequent form met with, both in health and disease. It is not 
yet determined what relations it holds to normal and abnormal condi- 
tions, or what is the true relationship between it and certain other bacteria. 
B. subtilis is another bacterium found both in health and disease. As 
above stated, there are various organisms which stain brown with iodo- 
potassic-iodide solution, and others which become blue with the same 
dye. Von Jaksch has studied these latter closely. They take various 
forms, as long or short rods, and take different shades of blue or violet. 
One of them is the Clostridium butyricum of Nothnagel. It occurs 
as large round cells, like yeast fungi, and stains like the tubercle bacilli 
with the Ziehl-Neelsen fluid. Von Jaksch finds these fungi in greater 
abundance in intestinal catarrh. They are present in both acid and 
alkaline stools. 

Bacillus Coli Communis has been found in the blood, various 
organs, faeces of cholera patients, in healthy faeces, in the air, and in 
putrefying infusions ; it also can be found in the peritoneal exudate in 
most cases of peritonitis. 

Morphology. A bacillus, 4 to 6 p by 2 to 3 with rounded ends, some- 
times in cultures a short oval. Five or more filaments have been 
observed. 

Biological Properties. Aerobic ; facultative anaerobic ; non-liquefying j 
as a rule, non-motile. 

Growth. On gelatin plates the colonies vary very much. The deep 



STOMACH, INTESTINES, AND PERITONEUM. 545 



Fig. 85. 



colonies are transparent straw color to dark brown, or may be granular 
and opaque. The surface colonies are large and spherical, centre dark 
brown, edges transparent. In stab cultures the surface growth is thin 
and dry. There is abundant growth along punctures, which is white 
by reflected but amber by transmitted light ; sometimes moss-like tufts 
are seen. On potato, a soft shining brownish yellow layer grows. 
Stains with anilines, but not by Gram's method. Injected in guinea- 
pigs, it produces fever, diarrhoea and collapse. Injected into abdomen 
of rabbits, causes a typical peritonitis. 

Pathogenic Fungi. Spirillum Cholera Asiatics. The Comma 
Bacillus. The comma bacillus of Koch is the specific causative agent 
of cholera. In a disease so widespread in time of epidemics, and so 
fatal, it is of great importance to be able to recognize the bacterium that 
produces it. Works on bacteriology give a fuller study than is permitted 
here, and should be consulted. This is more especially true because, 
while the bacilli, as found in the stools, can be stained quite easily, 
and may be recognized by expert microscopists, in the great majority of 
cases their recognition is only effected by bacteriological examination. 
They have no specific relation toward dyes, as have tubercle bacilli. 
The cholera bacillus is a short, more or less bent rod, both shorter and 
thicker than the tubercle bacillus, and generally shaped like a comma. 
They are often found placed end to end and thus form a curve like a 
spiral. They are always present in the stools of cholera patients and 
sometimes in the vomit. They are 
particularly abundant in the mucous 
floccules of the rice-water discharges, 
and can be obtained from the linen 
soiled by the same. Cover- slip 
preparations are made from these 
portions by placing a uniform film 
on the slip, drying it in the air, 
and then passing it through the 
flame of a bunsen burner or spirit 
lamp. 

The spirillum or so-called " comma 
bacillus" consists of a slightly curved 
rod, with rounded ends, 0.8 to 2f* 
long by 0.3 to 0.4 abroad. It is usu- 
ally slightly curved like a comma, 
but may form a half-circle, or two 
may be joined like an S. Under 
certain circumstances they grow out 
into long spiral threads. By Loffler's 
method a single flagellum is found 
on the rods. It stains with anilines, but slowly. An aqueous solution 
of fuchsin is best. (See Plate I., Fig. 3, A; and Fig. 85.) 

Biological Properties. Aerobic (fac. anaerobic), motile, liquefying. 

Growth. Grows in ordinary media at room temperature ; faster in 
oven. Does not grow except between 14° to 42° C. Gelatin plates: 
At the end of twenty-four hours small white colonies appear deep in the 

35 



I h hi 



'/ V / jH 



Cholera spirilla grown on moist linen. X 600. 
(After Koch.) Cultivated from the dejections 
after two days. 



546 



SPECIAL DIAGNOSIS. 



gelatin. These grow toward the surface and liquefy the gelatin iu a funnel 
form, which gradually deepens, and at the bottom the colony is seen as a 
small white mass. Under low power the colony is white or pale yellow, 
margins uneven, texture granular, surface looks as if covered with bits 
of glass. When liquefaction begins a dim halo forms about the colony, 
which by transmitted light is roseate in hue. 

Stab Cultures in Nutrient Gelatin. Develops all along the puncture, 
liquefaction beginning near the surface, forming a funnel which enlarges, 
and finally the gelatin almost entirely liquefies. (See Fig. 86.) On 
potato, a thin transparent grayish-brown layer. Milk, bouillon, blood- 




serum, are all favorable. In media with other bacteria it soon dies. 
Death-point, 52° 5'. In moisture it retains vitality for months, but is 
killed by drying. 

A test for this bacterium is the development of a purplish-red color on 
adding pure H 2 S0 4 to a culture in nutrient gelatin. 

To determine its presence in the shortest time, inoculate diluted 
bouillon. After ten to twelve hours a wrinkled film has formed. Make 
another culture in the same way from this, then inoculate gelatin plates, 
and use color test on these. Several toxins have been isolated. 

The bacillus of cholera nostras and one found in cheese by Deneke 
resemble the comma bacillus in shape, though somewhat larger, but they 
have bacteriological peculiarities by which they can be differentiated. 

Spirillum Cholera Nostras. Morphology. Longer and thicker; 
central part thicker than ends. Stains same as above. 

Biological Properties. Culture. A thick, stocking-like funnel of 
liquefaction instead of a fine, straight funnel. (See Fig. 87.) 



STOMACH, INTESTINES, AND PERITONEUM. 547 



Typhoid Fever Bacillus. This bacillus is present in the stools 
of typhoid-fever patients, but cannot be directly differentiated by micro- 
scopic examination alone, either when stained or unstained. It is 
necessary, for its detection, to make pure cultures according to bac- 
teriological methods. The bacillus is about as long as the tubercle 
bacillus but much thicker, being one-third as thick as it is long. 
The ends are rounded. It is best stained by concentrated aqueous 
solutions of methylene-blue, the dried preparations on the cover-slip 
being prepared as above. (See Plate L, Fig. 6, b; and Typhoid Fever.) 

Tubercle Bacillus. The bacillus of tuberculosis is frequently 
found in the faeces of persons suffering from intestinal tuberculosis and 
occasionally in the faeces of cases of pulmonary tuberculosis, when 
sputum containing bacilli has been swallowed. When tubercle bacilli 
are constantly found in the faeces, and in large quantities, it points to 
the former condition almost to a certainty. They are detected in the 
same manner as tubercle bacilli in the sputum. 

Bacilli of Booker. JSoless than nine bacilli have been described 
by Booker. Each of these has been found by him in cases of diar- 
rhoea in children. Seven of these resemble very closely bacillus coli com- 
munis. Bacillus A is a bacillus with rounded ends, 3-4^ by 0.7^. 
It is aerobic and facultative anaerobic, liquefying, and motile. Colonies 
on agar and potato are dirty brown. On gelatin they liquefy too soon 
to show characteristic form. 

This bacillus is found in the stools of cholera infantum. 

Chemical Examination. The chemical examination of the fasces is 
of but slight clinical value. Mucin and albumin are normally present; 
peptones, in different diseases (Von Jaksch). Among the acids to be 
found are bile acids, volatile and fatty acids, formic, acetic, butyric, and 
propionic acids ; while phenol, indol, skatol, cholesterin, and fats are 
always present, according to the same author. They will not aid in 
diagnosis. 

The normal coloring matter of the faeces is urobilin ; its presence is 
shown by the proper tests. As before stated, bile pigment never occurs 
in the faeces in health ; it is present when there is catarrh of the small 
intestine. Blood pigment is usually in the form of haematin. As 
might be expected, ptomaines have been obtained from the faeces of cer- 
tain diseases caused by fungi. 

Intestinal Indigestion. 

Intestinal indigestion is said to be due to alterations in or diminution 
of the bile, the pancreatic, or the intestinal secretion. It is almost 
always attended by gastric indigestion, and may not readily be distin- 
guished from it. Acute intestinal indigestion is due to the irritation of 
food not properly digested in the stomach. It is attended by colic, with 
flatulency and borborygmi. Some fever may arise, and diarrhoea ensue. 
In the mild forms the tongue is coated, there is loss of appetite, and 
some general pains. There is epigastric distress or pain in the right 
upper quadrant. There is flatulency and constipation. The stools 
are often clay-colored, or may not be changed. Slight jaundice occurs, 



548 



SPECIAL DIAGNOSIS. 



and there is an abundance of lithates in the urine. Accompanying 
gastric indigestion modifies the symptoms slightly. 

The symptoms are more marked and pronounced in chronic intestinal 
indigestion. The local symptoms are as follows : Pain which begins from 
two to six hours after eating. It may be complained of in the region of 
the liver or below the sternum. It is usually seated in the umbilical 
region. It is dull, continues two or three hours, or until the next meal is 
taken. There is some tenderness. With the pain there are tympanites, 
borborygmi and a sense of fulness in the abdomen ; the bowels are con- 
stipated, and the stools are hard and dry. The constipation alternates 
with diarrhoea, and undigested particles of food are passed. The appe- 
tite is not lost, but is variable. Hemorrhoids are often present. The 
general symptoms are marked, and are referred to the nervous system and 
the condition of the blood. There is great depression and hypochon- 
driasis. The patient sleeps badly, suffers from bad dreams and tinnitus 
aurium ; there are spots before the eyes and more or less constant head- 
ache. They complain of pain in the back and limbs, and hyper- 
esthesias or anaesthesias are present. There is inaptitude for mental 
exertion. Frequently the patient has sudden attacks apparently due to 
toxins, as sudden fainting, followed by collapse, or there may be vertigo. 
During these attacks there is great palpitation of the heart, and tachy- 
cardia. The extremities are cold and there are cold sweats over the 
body. Independently of the attacks, the patient is subject to palpitation 
and some dyspnoea. The urine is always high-colored, acid in reaction, 
and full of urates and uric acid. Oxalate of lime may be present, and 
the albuminuria of uric acid occurs. The patient is anaemic; the 
anaemia develops early. There is some emaciation; in some cases the 
emaciation is rapid. The complexion is sallow. If there is an abund- 
ance of oxalates the patient complains of weight and heaviness about 
the loins. The stools may contain fat, indicating probable pancreatic dis- 
ease, if fatty food has been ingested. On the other hand, with loss of 
appetite, furred tongue, frontal headache, and drowsiness, the stools 
may be clay-colored and the bowels costive ; apparently the bile is at 
fault. 

Acute Intestinal Catarrh. 

Cause* Exposure to cold or the direct irritation of mechanical or 
chemical substances within the intestine. Irritating food that is not 
digested, or that cannot be digested because of the quantity; spoiled 
meats and unripe fruits, usually excite an attack. Water saturated 
with impurities, or the natural characters of which the individual 
is not accustomed to, may excite an attack. Strangers in a new 
locality are frequently subject to a diarrhoea until accustomed to 
the drinking-water, which in the natives does not excite catarrh. 
Toxic substances, as poisons or drugs, or toxic substances the result 
of putrefaction, as ptomaines, are frequent exciting causes. Exten- 
sion of inflammation from neighboring structures by infection, as in 
peritonitis, sets up a catarrh. Local diseases of the intestine, as ileus, 
intussusception, hernia, and ulcers of all forms, are attended by catarrh 
of the intestine. In cachectic states of the system, as cancer, anaemia, 



STOMACH, INTESTINES, AND PERITONEUM. 



549 



and Bright's disease, catarrh occurs. In diseases of the heart and blood- 
vessels, or of the liver and spleen, on account of which the disturbance 
of the circulation causes a congestion, catarrhal inflammation occurs. It 
is of common occurrence in the infectious diseases, and particularly in 
septicaemia and pyaemia. 

Symptoms. Diarrhoea is the chief symptom, varying with the cause 
and the extent of the catarrhal inflammation. The stools differ in 
frequency and in color, as has been previously indicated in the vari- 
ous types, and, depending upon the cause, contain undigested matter or 
worms. Colicky pains about the umbilicus, with borborygmi and fre- 
quent desire to go to stool, attend most forms. Each evacuation is pre- 
ceded by the above symptoms. Fever of the remittent type, with some 
prostration, attends. The urine is scanty and high-colored. The symp- 
toms vary somewhat with the location of the inflammation, although 
the exact locality cannot be as distinctly defined as at one time was 
thought possible. It is nevertheless true that in proctitis there 
are rectal symptoms of pain with tormina and tenesmus. These 
are more common than in inflammation which is apparently limited to 
the small intestine, while in colitis the degree of the rectal symptoms 
stands between enteritis and proctitis. 

The diagnosis of acute intestiual catarrh is not difficult. It is more 
difficult to determine the actual cause. If the attack occurs suddenly 
following the eatiug of improper food, or the drinking of impure water, 
the irritation is probably due to that cause. The cause may be deter- 
mined by the nature of the faeces. If they contain undigested food the 
diarrhoea is probably due to indigestion. Catarrh from cold usually 
follows exposure, and is generally not very severe. To estimate the 
cause from poisons or drugs the condition of the rest of the intestinal 
tract must be investigated and other symptoms of the effects of drugs 
must be inquired for. In arsenical poisoning there is always vomiting, 
and the discharges are of a choleraic nature. Collapse rapidly ensues. 
The other symptoms of arsenical poisoning must be inquired for and 
the history of exposure, if possible, ascertained. The intestinal catarrh 
due to infectious diseases is attended by the symptoms due to the respec- 
tive affections, each of which is usually readily recognized. It may 
be necessary to resort to a bacteriological examination of the faeces. The 
intestinal catarrh which occurs on account of local disease of the bowel, 
as hernia, stricture, etc., is preceded or attended by the local symp- 
toms of these diseases. In like manner we judge of the nature of the 
diarrhoea that occurs in the course of tuberculosis or syphilis, and in 
the course of organic heart disease or of liver disease. In each instance 
the possible influence of morbid processes present in other structures 
must be very carefully estimated. 

The Varieties of Acute Intestinal Catarrh. Divisions have 
been made in accordance with the symptoms which distinguish the vari- 
ous localities of the intestine in which the inflammation is most marked. 

Catarrh of the Duodenum. This partakes of the nature of the symp- 
toms of gastro-intestinal catarrh in a mild degree, and is characterized by 
the occurrence of jaundice due to catarrhal inflammation of the biliary 
passages. 



550 



SPECIAL DIAGNOSIS. 



The Small Intestine. Colicky pains and rumbling are experienced. 
There is usually gastritis at the same time. The faeces are mixed with 
mucus. Over the right lower quadrant there is tenderness ou pressure. 

Ccecum. Pain in the right lower quadrant with tumor, dulness on 
percussion, with tenderness, are present. (See Typhlitis.) 

Colitis. The large intestine is most frequently affected. Pain and 
tenderness along the course of the bowel. The evacuations contain 
mucus; there is tenesmus. 

The Rectum. Proctitis gives rise frequently to small stools, tenesmus, 
pain in the left lower quadrant, with tenderness about the anus and 
spasm of the sphincter. There is considerable mucus and blood in the 
passages. 

Cholera Infantum. This affection occurs in children during the 
hot season. It is promoted by bad hygienic surroundings and is due to 
improper milk or food. At first there is catarrhal diarrhoea. This 
may continue for twenty-four hours, then vomiting and diarrhoea ensue. 
The stools are liquid and large in amount. At first they may contain 
milk curds. The vomiting is excited by anything taken into the mouth, 
or by odors, or by movement of the little patient. The watery discharges 
are almost constant. They may be preceded by greenish or yellowish- 
green stools for twenty-four hours. Stools are acid in reaction, and 
their odor is sour. At first there is colicky pain, but when the watery 
discharges begin there is only a little tenesmus. The abdomen is at 
first distended with gas, but soon becomes retracted. The fasces irritate 
the skin and cause eczema. The rectum may become prolapsed. In a 
short time, twenty-four hours or even less, collapse ensues. Previous 
to the collapse the skin is hot and dry, patient restless, the thirst in- 
tense, the mouth dry. The body temperature is 103° to 104.° With 
collapse the extremities become cold, the skin cool. The axillary tem- 
perature is lowered and the rectal temperature increased to 105° to 
106.° The restlessness continues, the fontanelles become depressed, the 
eyes sunken, the face pinched, the brows drawn. The urine dimin- 
ishes in amount or may disappear entirely. Brain symptoms ensue. 
So-called hydrocephaloid symptoms follow — rolling of the head, 
strabismus, turning in of the thumbs, and later, convulsions. Stupor 
followed by coma develops in the fatal cases. If the patient does not 
die in collapse, marasmus develops ; ulceration of the cornea may take 
place; there is oedema and blood extravasation under the skin. The 
child emaciates and withers. On account of the weak heart and ex- 
haustion, pulmonary atelectasis or broncho-pneumonia may occur. The 
age, the season, the presence of the catarrh, with collapse and other 
symptoms, render the diagnosis easy. 

Entero-colitis. Iu eutero-colitis the more intense inflammation 
succeeds a mild intestinal catarrh. There is increased languor, great 
fretfulness, and fever. The early catarrh is attended by green acid 
stools, with lumps of casein. The tongue is furred and moist at first. 
It soon becomes red and dry; vomiting ensues. The stools are offensive 
and increase in frequency, and, in addition to the appearance first indi- 
cated, contain mucus and blood. Death may take place within the first 
week on account of exhaustion from the vomiting and diarrhoea. If 



STOMACH, INTESTINES, AND PERITONEUM. 



551 



the disease is protracted there are great wasting, symptoms of hydro- 
cephalus, skin eruptions, hypostatic pneumonia, and extremely weak, 
feeble circulation. 

Acute Dysentery. The term dysentery is applied to an inflam- 
mation of the intestinal tract, chiefly the colon, which is attended by 
the symptoms of intestinal catarrh in intense degree, characterized by 
mucus and bloody discharges, with the severe general symptoms of fever 
and prostration, followed by extreme exhaustion, the occurrence of 
abscesses in the portal circulation, or of paralysis, arthritis, nephritis, or 
profound ansemia. It was thought to be an epidemic disease which 
was mildly contagious. Although of frequent occurrence sporadically, 
it is common in jails aud institutions, in camps, or where people are 
crowded together, when at the same time hygienic conditions are most 
unfavorable. It usually occurs in the summer or fall, and is attributed 
to the drinking of impure water. A form most common in the tropics 
is called tropical dysentery. Recent investigations have shown that 
catarrhal dysentery due to the above-mentioned circumstances may 
occur, and that in addition " tropical " dysentery, although not confined 
to the tropics, is associated with inflammation and ulceration of the 
bowel, attended by the amoeba dysenterise or A. coli. 

Catarrhal dysentery may be limited to the simple inflammation of 
the intestine, or may be followed by ulceration. Its first symptoms are 
those of intestinal catarrh. There is indigestion, with loss of appetite, 
perhaps vomiting, and the occurrence of slight diarrhoea. These symp- 
toms may have immediately followed a diarrhoea or a chill may take 
place after they have continued three or four days. The diarrhoea is 
attended by pain, at first seated around the umbilicus ; it then becomes 
marked in the course of the colon. The movements are frequent, pre- 
ceded by constant desire, aud attended by extreme tenesmus. The 
stools, which were first faecal and fluid, soon become scanty, and consist 
almost entirely of mucus and blood. The symptoms of local proctitis 
are intense; there is a sensation of a hot mass in the rectum. There 
may be strangury, and prolapse of the anus may ensue. 

With the active pain aud frequent evacuations the skin is hot and 
dry; there are thirst, nausea, and occasionally vomiting. The tempera- 
ture continues at about 103° ; the pulse is rapid. There are restlessness 
and weakness ; the tongue is red and raw. 

If the disease is severe from the start, or the course is unfavorable, 
stools may contain pure blood, or are dark in color, and may contain 
shreds of membrane. Pain and tenesmus disappear, and the evacua- 
tions become constant or involuntary. Restlessness becomes more 
aggravated ; the extremities becomecold ; mild delirium sets in The toss- 
ing and restlessness are quite characteristic, and are attended by sigh- 
ing and some dyspnoea. The pulse is rapid and feeble ; the heart sounds 
are weakened ; the tongue becomes dry and brown, the mouth is parched, 
and thirst is intense ; ulcers develop in the mouth and sordes collect 
around the teeth. The delirium increases to stupor, and from that to 
coma. The urine, at first high-colored and scanty, becomes bloody and 
contains albumin and casts. Although the fever is continued during 
this stage, the extremities become cool, perspiration breaks out over the 



552 



SPECIAL DIAGNOSIS. 



forehead, and, iustead of typhoid symptoms, the symptoms of collapse 
may ensue. If the disease is prolonged and the bowels controlled, the 
symptoms of pyaemia may develop. 

The anaemia that ensues is extreme, and wasting is prominent. Con- 
valescence is slow and may be attended by chronic diarrhoea. Before it 
is established ulcers of the skin may form on various parts of the sur- 
face of the body. Arthritis is of common occurrence, and paralysis may 
occur during convalescence or after an attack has subsided on account 
of peripheral neuritis. Chronic dysentery may succeed the acute. It 
is thus seen that the attacks may be of moderate severity or extremely 
grave ; during the course of the latter gangrene of the lower bowel 
may take place. 

Amcebic Dysentery. This differs from catarrhal forms of dysentery 
in many respects. The onset may be abrupt or gradual, as in the previous 
form, with symptoms of intestinal catarrh. In most of the cases a frequent 
and painless diarrhoea follows a period of slight ill health. The diar- 
rhoea alternates with short periods of constipation ; the stools are watery 
and contain mucus, but no blood. The course of the disease is irregular. 
There may be intermissions and exacerbations of the diarrhoea without 
obvious cause. It may rapidly pass from one grade to another, or be- 
come chronic. One form is the gangrenous, which may scarcely be 
appreciated by the symptoms until the autopsy shows it to have been 
present. True relapses are common, and the tendency to chronicity is 
very great. In the milder cases there are weakness, emaciation and pallor ; 
the expression is dull ; the skin is dry and sallow ; the tongue pale, 
flabby, and moist, slightly furred ; the abdomen is normal or retracted ; 
the temperature does not rise above 100°, and the pulse ranges from 70 
to 90. Sleep is disturbed by frequent evacuations of the bowels. In the 
grave form the face is drawn, or cyanosed or flushed, the expression 
anxious ; the mind is clear. There are anorexia, intense thirst, and 
sleeplessness. The abdomen is greatly retracted, and there may be free 
sweating. The temperature is normal or subnormal ; the pulse small and 
rapid. Progressive anaemia and loss of flesh are prominent and domi- 
nate the intestinal symptoms. The skin is dry and harsh, and of a 
dull greenish-yellow color if the cases are protracted. 

The special features of amoebic dysentery are : ] . The ancemia. This is 
due to diminution of the red cells and the haemoglobin, first, because of 
the action of the amoebae upon the red blood-corpuscles, which they de- 
stroy ; second, the direct loss of blood ; and, third, malnutrition. The 
first is the most predominant. 2. Diarrhoea may be the only feature 
of the disease. It is characterized by great variation in character and 
frequency in all grades and during different periods of the disease. 
Intermissions and exacerbations may be observed at any time. The 
latter begin suddenly, and subside in the same manner. They may last 
from two to ten days. The intermissions continue from one day to three 
weeks, during which the faeces are soft, but contain mucus. Council- 
man and Lafleur have observed this periodicity to be most marked in 
cases complicated with hepatic abscess. 

3. The Stools. The stools are extremely variable in accordance with 
the severity of the ulceration, and also vary in number and character from 



STOMACH, INTESTINES, AND PERITONEUM. 



553 



day to day in individual cases. In the gangrenous form they number 
thirty or forty in twenty-four hours at first, then decliue, so that toward 
the end of fatal cases but three or four take place. At first the move- 
ments are small and consist of mucus with more or less bright blood 
and small faecal masses. As ulceration advances the stools change, they 
become more copious and watery, fasces are absent, blood is not so 
frequent. Shreddy masses of grayish or yellow color appear mixed 
with mucus. If there is sloughing they become greenish or grayish, 
resembling spinach, or reddish-brown and very liquid or pultaceous. 
The odor is penetrating and offensive. Shreddy masses of necrotic 
tissue are discharged. Gray liquid movements, somewhat slimy, contain 
more pus than the others. Small opaque, or translucent, gelatinous 
grayish masses, one to three cubic millimetres in diameter, are found in 
the stools. 

In the more moderate types the stools at the outset are like those of 
gangrenous dysentery if the attack is abrupt. If gradual, the stools are 
fsecal, liquid, containing mucus and streaks of blood and many of the 
gelatinous grayish masses. Stools of this character number from four 
to ten in twenty-four hours; this may continue for weeks. During the 
exacerbations the stools resemble those of the second period of the gan- 
grenous form. In chronic dysentery there is not so much mucus or blood, 
except in exacerbations. The stools are of the consistence of thin gruel 
and have an earthy or dull yellow color. Mucus is persistently 
present, however, in the intermissions, when the stools are soft and 
faecal. 

The reaction of dysenteric stools is generally alkaline. 

Microscopical Examination. In the mucoid and bloody stools of the 
acute stage red blood-corpuscles, leucocytes, and large, round, or oval 
epithelioid cells are seen. The latter are often in groups of three or 
more. The nucleus is about the size of the red blood-corpuscle, the 
protoplasm granular. Their outline is sharp. They may be taken for 
amoebae They are non- motile and refract light less strongly. Cerco- 
monas intestinalis is present, but bacteria are not abundant. In the 
later periods the cell elements are less numerous ; shreddy and mus- 
cular detritus and bacteria are observed, with elastic tissue fibres. 
Charcot's crystals and phosphates are seen. In chronic dysentery the 
cell elements are still fewer and amoeba? easily detected. 

Amosbce. Amoeba? are found at all periods of the disease. They vary 
in different cases and at different periods in proportion to the severity 
of the intestinal ulceration. They are most abundant in the grayish- 
yellow gelatinous masses, next in the particles of clear or opaque 
mucus, and finally in the fluid portions of the stools. In chronic dys- 
entery they are found in all portions. In the intermission of the diar- 
rhoea they may be found in the particles of mucus adherent to the faeces. 
They disappear as recovery proceeds, although they may be seen after the 
evacuations become normal. They vary in size and activity. They 
are more common in the alkaline and neutral stools. They are scarce 
and are rarely motile in acid stools. In the more active forms red 
corpuscles are seen. 

For their detection the following should be observed : First, the stools 



554 



SPECIAL DIAGNOSIS. 



should be passed in a warm bed-pau and kept at a temperature of 30° 
to 35° C. until an examination is made. Second, this should be done 
before the stools become acid. Third, the portions of the stools pre- 
viously mentioned should be selected for examination. They contain 
amoebae in greatest abundance. A magnifying power of four hundred 
diameters is required, although they may be seen with less. 

Description of the Amoebce. When inactive they are round or slightly 
oblong, are highly refractive, and contain vacuoles of greater or less 
size. The latter are clear, and vary from small points to one-third of 
the diameter of the aureola. The ecto- and endosarc may or may not 
be sharply divided. If they are, the outer is hyaline or homogeneous, 
the inner is more refractive and contains vacuoles. They are difficult 
to recognize in this condition, being mistaken for swollen connective- 
tissue cells. The amoebae frequently enclose red corpuscles, pus cells, 
blood pigment, bacilli and micrococci. In afresh state the nuclei cannot 
be made out because they resemble vacuoles. The endosarc is not 
granular, is composed of a dense substance and is highly refracting. 
When active the movement is characteristic. It may be slow or rapid, 
and is of two kinds, a progressive movement and one limited to the 
throwing out of pseudopodia. The movements appear to be rhythmical 
in some cases, occurring at regular intervals. The movement is sudden 
and characterized by change in form of the pseudopodia. The ecto- 
and endosarc are clearly defined usually. The pseudopodia are alkaline 
and homogeneous, like the ectosarc. The amoeba changes its position 
sometimes by enlargement of the pseudopodia, into which the inner- 
contents of the older part follow. The movements are increased when 
the examinations are made on the warm stage. 

In catarrhal dysentery the stools are uniform in character, quantity, 
and frequency. The onset is sudden, and evacuations consists of bright 
blood and viscid, clear mucus mixed with faecal matter. They soon are 
composed entirely of mucus and a little blood. The mucus is viscid. 
In a week or ten days the mucus changes and becomes grayish-white in 
color, is less blood-stained and brown ; pultaceous or fluid faecal matter 
appears in the stools. As the blood and mucus disappear, formed faeces 
return. Iu the prolonged cases the stools are soft, yellowish-brown, or 
greenish, in addition to the bloody mucoid stools. The frequency is 
greatest at the onset and progressively diminishes until convalescence is 
established. The more frequent the evacuations the smaller the size of 
the stools. The mucoid stools are small, pultaceous, more bulky. On 
microscopical examination red and white corpuscles, cylindrical epithelial 
and oval epithelioid cells are seen. The latter are very characteristic, 
and occur singly or in groups. Bacteria are more common as improve- 
ment sets in. In the pultaceous stools the cell elements are scarce. In 
diphtheritic dysentery the stools are watery. They resemble meat wash- 
ings — evacuations such as are described in cases of gangrenous dysentery. 
They are grayish-greeu or reddish-brown and very offensive. Mucus is 
present iu small amounts. At first unclotted blood is present, afterward 
minute dark red clots are seen. Shreddy and finely divided material, 
gray or reddish-brown in color is present, but there are no sloughs. The 
stools are not numerous at first, and average from seven to fifteen daily 



STOMACH, INTESTINES, AND 



PERITONEUM. 



555 



during the course of the illness. The quantity passed is small. Cylin- 
drical epithelial cells are most abundant on microscopical examination. 
Red blood-corpuscles and leucocytes are observed, but fibrin constitutes 
the larger portion of the stool. In all the stools bacteria are present in 
great numbers. 

Other Symptoms of Amoebic Dysentery. Abdominal pain is constant ; 
it occurs in the early stages of both forms and in acute exacerbations. As 
the movements diminish the pain decreases. In the gangrenous form 
pain also disappears, although the intensity of the process is increasing. 
In chronic cases the colic is complained of during the exacerbations ; 
during the intervals a dull aching or burning pain is complained of in the 
upper quadrants. In all cases the pain is cramp-like, boring, or burning 
in character, and usually precedes and accompanies movements of the 
bowels. When severe, it is general ; but it is usually localized in the lower 
abdominal zone. Moderate tenderness on pressure can be elicited in most 
cases along some part of the course of the large bowel. In catarrhal 
dysentery tenesmus is common ; in the amoebic form it is infrequent. 
A burning sensation in the rectum and at the anus during and after the 
passage of faeces is generally complained of. Nausea and vomiting 
occur at the outset, or at irregular intervals, caused by improper food, 
or on account of complications. Hiccough occurs in the terminal stages. 

Fever. In amoebic dysentery fever is not a prominent feature, 
although there is usually a moderate rise in temperature. In the gan- 
grenous form it is normal, or may be subnormal for days. Chronic 
dysentery is afebrile. In exacerbations of diarrhoea slight fever may 
occur. Complications cause a higher temperature If fever is present 
it may be remittent or intermittent in character, or if the illness is pro- 
longed at any time, first continuous, then remittent and then intermittent. 
If the latter, the usual morning fall is observed, although an inverse 
temperature may be present. Rigors occur with the complications. 
Sweating is observed, with subnormal temperature, in the gangrenous 
form. In cases of abscess the fever is intermittent or remittent. 

In chronic dysentery the skin is excessively dry. The circulation 
and respiration are influenced by the pyrexia. Ansemia is pronounced. 
When exhaustion ensues the pulse becomes more feeble, compressible 
and rapid. The urine is albuminous, and often contains casts. In 
the gangrenous form there may be retention of urine. 

The complications of amoebic dysentery are: 1. Hepatic abscess, or 
hepato-pulmonary abscess. 2. Peritonitis. 3. Hemorrhage from the 
bowels. 

Abscess may develop in all forms and at any period of the disease. 
The time of the disease at which it occurs caunot be determined defi- 
nitely. In the subacute cases it is liable to develop from the fourth to 
the twelfth week. The abscess may develop on the convex surface of 
the right lobe of the liver near the coronary ligament. In these cases 
the lung also becomes involved. Couucilman and Lafleur suggest that 
infection takes place by the peritoneum. (See Abscess of the Liver.) 

While the symptoms of abscess of the liver will be treated of under 
the section devoted to liver disease, it is important to note that hepatic 



556 



SPECIAL DIAGNOSIS. 



symptoms may occur in cases in which, on account of the mildness of the 
disease, the local bowel trouble may be overlooked entirely. If the 
association of hepatic pain with fever and discharge of mucus from 
the bowels is observed, it is barely possible, even if an examination 
of the fa3ces cannot be made, that an hepatic abscess is present. 
If in addition, cough and expectoration occur, involvement of the 
lungs is possible. The character of the expectoration points conclu- 
sively to the nature of the lung complication. After a period of dry, 
hacking cough, sudden expectoration of mucopurulent or bloody sputum 
takes place. It is of a dirty red or brownish puriform color. From this 
time on this material is expectorated in varying quantities after a par- 
oxysm of coughing. The expectoration is diffluent, tenacious, and frothy. 
It varies in color from bright red to russet brown ; it may be bile-stained. 
The sputa are alkaline ; the odor is not putrid. At a later period they 
become more purulent, and contain less blood. The sputum separates 
into three layers : an upper frothy layer, a middle layer of turbid fluid, 
a thin layer of muco-pus below. Large amounts may be coughed up in 
twenty-four hours ; the sputa contain, on examination, blood-corpuscles, 
leucocytes, round alveolar epithelial cells and polyhedral, fatty degen- 
erated cells which look like liver cells. Elastic tissue fibres from the 
lungs are found with crystals of hsematoidin and tyrosin, and Charcot's 
crystals. Bacteria are present. Amoebae are constantly present. They 
vary in size and activity, but are larger than those seen in the stools. 
The sputum should be kept warm and examined for them as soon as 
possible. 

Peritonitis. Peritonitis from perforation is not a common complication 
of amoebic dysentery, but occasionally takes place in the gangrenous form. 
Peritonitis without perforation may occur. The symptoms do not differ 
from peritonitis under other circumstances. Hemorrhage from the bowel 
occurs and may be sufficiently profuse to cause death. Other complica- 
tions which have been described under catarrhal and croupous dysentery 
are likely to occur in this affection. 

The Diagnosis. The diagnosis of this form of dysentery is made abso- 
lute by finding the amoebae in the stools. The history and the course of 
the illness must also be taken into consideration, the characteristics of 
which have been previously detailed. The irregularity, and the intermit- 
tency of the diarrhoea, the infrequency of tenesmus, the moderate fever, 
the reaction of the stools, and their comparative freedom from bacteria, 
are further corroborative points. 

Cholera Morbus. The attack is characterized by sudden vomit- 
ing, followed in a short time by purging. The vomiting may be 
preceded by pain, or both may occur at the same time. At first the 
pain is seated in the epigastrium and subsequently about the navel. 
It is very severe and paroxysmal in character, compelling the patient 
to double up if lying in bed. A cold perspiration breaks out on 
the forehead, the extremities become cold, the face is anxious, the 
pulse becomes rapid. At first the patient vomits undigested food, then 
watery, greenish-colored fluid. The latter is bitter. Purging sets in 
at once, or within an hour. The bowel movements follow an attack of 
pain. The first passage is fsecal, and may contain undigested food, the 



STOMACH, INTESTINES, AND PERITONEUM. 557 



subsequent passages are watery and profuse. There are severe attacks of 
burning and tenesmus ; the abdomen is tender around the navel and in 
the epigastrium. After an evacuation there is slight relief, but soon 
another paroxysm of pain comes on. The vomiting is excessive, and 
retching may be present in the intervals. Ice, or water, or anything 
taken into the stomach excites pain and causes the vomiting. The attack 
subsides in twelve to twenty-four hours, followed by exhaustion. In 
rare cases collapse ensues, and in others it is followed by gastro-intestinal 
catarrh. 

Cholera Nostras. This affection occurs in epidemics in hot weather. 
The symptoms are those of severe gastro-enteritis. There is sudden vomit- 
ing and diarrhoea. It usually begins in the night. The vomiting is 
not different from that of cholera morbus. The watery and brownish- 
colored stools become colorless and have the appearance of rice water. 
Pain attends the attack, rapid prostration ensues, the extremities become 
cold, and collapse takes place. With the collapse there are cramps in 
the legs. Other muscles of the body may become cramped. The dis- 
ease occurs in epidemics during the hot season, and may be mistaken for 
cholera. It can only be distinguished from the milder forms of cholera 
which precede the occurrence of the epidemic by the absence of the 
comma bacillus. The bacillus of cholera nostras is found in the stools. 
(See Faeces.) 

Chronic Intestinal Catarrh. It usually follows an acute attack, 
or may be chronic from the start. It arises secondarily to portal con- 
gestion in disease of the liver or spleen, to chronic disease of the heart, 
or of the lungs. It occurs in malaria and in the scorbutic cachexia. 

The symptom is diarrhoea alternating with constipation, or diar- 
rhoea alone occurs. Stools may contain undigested food, or pus and 
mucus and blood in small amounts. Diarrhoea may be present in the 
morning only, under these circumstauces. If the faeces are examined, 
the eggs of parasites, or infusoria may be found. The local abdominal 
symptoms of rumbling, flatulency, and tormina are present. There 
are reflex symptoms of cardiac palpitation and dyspnoea (asthma). 
Rush of blood to the head may occur. Often these symptoms are 
relieved by the passage of flatus. Chronic catarrhal gastritis usually 
accompanies the intestinal catarrh. The general symptoms of anosmia, 
emaciation and neurasthenia are present. Hemorrhoids are common. 

Ulceration of the Intestines. 

Duodenal Ulcer. Ulcer of the duodenum usually occurs in young 
subjects in whom there are symptoms of chlorosis or anaemia. The causes 
of gastric ulcer usually exist. It may follow boils, erysipelas, or pem- 
phigus, and differs in one etiological respect from ulcer of the stomach in 
that it occurs most frequently in the male sex. The symptoms are obscure, 
and may be wanting entirely, the patient probably complaining only of 
intestinal indigestion. In other cases they are like those of gastric 
ulcer. In typical cases the symptoms are those of pain situated 
below the xiphoid or to the right of the median line in the region 
of the pylorus. The pain occurs after eating, and may be relieved by 



558 



SPECIAL DIAGNOSIS. 



vomiting. There is localized tenderness on pressure. Hemorrhage may 
take place from the stomach, or blood be found in the stools alone. It 
differs from gastric ulcer only in the possible difference in location of 
the pain, the occurrence of intestinal indigestion and gastric hemorrhage, 
and the fact that the pain continues several hours after eating. 

General Ulceration. Ulceration of the intestine may be due 
to a specific infection, and hence symptomatic of typhoid fever, syphilis, 
and tuberculosis. It is always present in the former, and of frequent 
occurrence in the latter. Follicular ulceration occurs in entero-colitis 
in children. Ulcers due to the pressure of faeces occur in typhlitis 
and chronic constipation. The sacculi of the colon become filled with 
scybalous masses, the pressure of which produces ulcers. Tenderness 
is experienced along the course of the colon, particularly on palpa- 
tion of the fsecal masses which may be felt through the abdominal wall. 
A non-specific chronic ulcerative colitis is the form that succeeds the diar- 
rhoeas which occur during camp life, or that are set up in communi- 
ties where people live closely under bad hygienic circumstances. It 
is the form that attends scurvy, and is frequently seen in chronic 
Bright's disease. It may be succeeded by dilatation of the colon, 
by hypertrophy of the muscular walls, or by contraction of the bowel. 
The persistent diarrhoea leads to profound emaciation, extreme prostra- 
tion, sallow complexion, with markedly impaired nutrition of the skin. 
Such forms of diarrhoea were seen during the late war, particularly in 
soldiers held in captivity. The diarrhoea may first be of a lienteric 
character, and later alternate with constipation. Stools contain blood 
and mucus. Most of the pensions given to soldiers at the present time 
are given because of this disease. 

Ulcers of the intestinal tract may occur from other causes and diar- 
rhoea be the prominent symptom. They may be due to cancer; the 
malignant nodules may ulcerate within the lumen of the bowel. The 
bowel may be perforated from the exterior, on account of suppuration 
somewhere along its course, as in appendicitis, pancreatitis, or tubercu- 
lous peritonitis. The symptoms of intestinal ulcer are those of diarrhoea. 
Ulceration, however, may be present without any symptoms whatsoever, 
particularly if the small intestine is affected. One or two small ulcers, 
on the other haud, in the lower portion of the colon may set up con- 
tinuous diarrhoea. The stools are composed of feces, mucus, pus, shreds 
of tissue, and blood. If pus is discharged in large amounts an abscess 
has probably opened into the bowel. Moderate discharge of pus usually 
follows ulcers in the colon. Pus may be present in cancer. Hemor- 
rhage is of frequent occurrence, and is an important diagnostic symp- 
tom, especially if profuse and occurring without symptoms of obstruction, 
of gastric ulcer, or of hemorrhoids. The fragments of tissue found in 
the stools may point to the nature of the process. Large amounts attend 
the dysenteric process. The fragments may be composed of the mucosa, 
connective tissue, and the muscular coat. Pain occurs in many of the 
cases. It may be general and colicky, or circumscribed in cases of ulcer 
of the colon. Perforation of the intestine is followed by localized or 
general peritonitis. The occurrence of the latter depends largely upon 



STOMACH, INTESTINES, AND PERITONEUM. 



559 



the situation and the rapidity of the ulceration. If the perforation is 
in the posterior wall of the colon a circumscribed abscess may develop. 
When it is situated in the upper zone the pus may accumulate under- 
neath the diaphragm, or in the lesser peritoneal cavity. The signs of 
pyo-pneumothorax subphrenicus occur when the latter accident takes 
place, as both pus and air accumulate in the abscess cavity. In such 
instances the ulceration usually takes place at the splenic flexure. Per- 
foration of an ulcer of the caecum may simulate appendicitis. 

Intestinal Obstruction. 

Intestinal obstruction may be acute or chronic, depending upon the 
cause of the disease. Acute intestinal obstruction is due, first, to constric- 
tion by bands or strangulation of the bowel through apertures ; second, 
to volvulus of the colon ; third, to acute intussusception. In the first 
instance the type of the obstruction is seen in strangulated hernia, but 
similar strangulations occur in apertures within the peritoneal cavity. 
Thus, loops of the intestine are caught and constricted in the duodeno- 
jejunal fossa, the so-called Trites' retro-peritoneal hernia, or in the fora- 
mina of Winslow, also known as inter-sigmoid hernia; finally, diaphrag- 
matic hernia, in which protrusions of the intestine into the diaphragm 
along with other abdominal viscera may take place. The above-men- 
tioned forms of hernia may exist without symptoms, or may, from some 
unknown cause, lead to constriction or twisting of the loop of the intes- 
tine, with the occurrence of acute obstruction. Abnormal lacerations 
in the omentum may give rise to internal constrictions. Internal 
constrictions, however, take place, most commonly in the regions of 
hernias, on account of the gut being constricted by dense fibrous adhe- 
sion ; or about the uterus or Fallopian tubes, which had previously been 
the seat of inflammation. The constricting bands that follow the local 
peritonitis may gradually occlude the gut, or be in such position that the 
latter becomes twisted about it. In other forms of peritonitis similar 
constricting bands may form, which are liable to produce this accident. 
Disease about the vermiform appendix, with secondary adhesions, has 
been observed to cause constriction. A frequent form of intestinal 
obstruction is due to the tangling of the intestine in the foetal remains 
of the omphalo-mesenteric duct, which, as well as Meckel's diverticu- 
lum, is situated a short distance above the ileo-csecal valve. 

Volvulus is a form of obstruction due to twisting or knotting of the 
intestine. The condition is not common. It occurs most frequently 
at the sigmoid flexure of the colon. The mesentery of the latter is 
often congenitally narrowed, on account of which the colon is unduly 
dragged upon, and, if filled with masses of faeces, cannot restore itself ; 
the twisting becomes permanent, and obstruction takes place. Peri- 
stalsis is set up and other portions of the intestine wind about the ped- 
icle of the loops so as to form a regular knot. Abnormal peristalsis on 
account of diarrhoea often precedes the appearance of the obstruction. 
External injury is said also to give rise to the formation of an obstruc- 
tion. 

Intussusception, as a cause of intestinal obstruction, occurs most 



560 



SPECIAL DIAGNOSIS. 



frequently in children, and is due to a portion of the bowel being 
pushed into the lumen of that which lies next below it. A circum- 
scribed portion of the intestine may be paralyzed. In the portion 
above, the peristaltic action continues and the energetic movements push 
it into the paralyzed part. Intussusception is found frequently after 
death in the bodies of children dying from exhaustion. In such cases 
it occurs just before death. Intussusception also occurs when intestinal 
polypi drag one portion of the bowel into the lower portion. Large 
portions of the intestine may be involved. The invagination usually 
takes place at the lower portion of the ileum, or in the caecum ; some- 
times the invaginated portion may reach the rectum and project exter- 
nally. Intense inflammation and adhesion are set up. The internal 
portion becomes gangreneous on account of constriction of the afferent 
vessels. This portion may slough and pass with the dejections, fol- 
lowed by spontaneous cure. 

Intestinal obstruction, to view it from another standpoint, may be due 
to (a) diseases outside of the intestines ; (b) to disease in the intestinal 
walls ; (c) to accumulation within the intestine. 

The obstruction takes place under the same circumstances as obstruc- 
tion in other channels. 

A. Diseases Outside of the Intestines. 1. Pressure of tumors, chiefly 
ovarian tumors, uterine tumors, tumors of the omentum, and pelvic 
abscess, or abscess about the caecum. The symptoms of obstruction 
develop gradually, although rarely they may take place suddenly, espe- 
cially if aided by the accidental occurrence of faecal impaction. 

2. Constricting bands, hernial openings, the remains of foetal struct- 
ures, cause constriction of the intestine. In this class of cases there is 
usually pain, and the history preceding* the obstruction is that of peri- 
tonitis, general or local, of old hernia, of appendicitis, of pyosalpiux, or 
of inflammation about the gall-bladder and gall-ducts. If the con- 
striction is due to protrusion into hernial openings, the onset is usually 
sudden and without previous symptoms. 

3. Peritonitis is the most common cause of intestinal obstruction. It 
may be due to overdistentiou by gas and paresis of the bow T el, or to 
pressure by external exudation. 

4. Knots and twists of the intestines, usually seated about the 
sigmoid flexure, causing volvulus, are a common cause of constriction. 

B. Disease of the Intestinal Walls. 1. Invagination, or intus- 
susception, in which one portion of the bowel is drawn into the 
other. It usually occurs in children and is seated in the right lower 
quadrant in the neighborhood of the caecum. The attack is acute, 
although the affection may continue over a long period of time. 

2. Cancer of the intestine in its course generally leads to stricture 
and obstruction. 

3. The healing of ulcers, which are syphilitic in the larger number of 
cases, rarely tuberculous, will lead to stricture. The obstruction takes 
place gradually in this class of cases. It is seated, in the larger number 
of instances in the rectum or sigmoid flexure of the colon. 

C. Accumulations Within the Intestines. 1. Faeces. The obstruc- 
tion takes place gradually, occurs in weak and debilitated people 



STOMACH, INTESTINES, AND PERITONEUM. 



561 



in the course of constipation, and follows the constipation of acute 
disease. 

2. Accumulations of improper food or foreigu materials. The seeds 
of fruits or the husks of grain accumulate and cause obstruction. Mag- 
nesia, iron, and other articles taken as medicines, from their accumula- 
tion lead to obstruction of the intestine. In these instances the obstruc- 
tion takes place gradually. 

3. Impactiou of gall-stone within the intestine is followed by acute 
obstruction. 

It will be observed in the detailed list of causes that obstruction may 
be acute or chronic. Complete acute obstruction may set in in the 
course of chronic obstruction due to stricture of the bowel, and occlusion 
due to external pressure or to accumulations within the bowel. 

In a case in which the symptoms of intestinal obstruction occur it is 
important to ascertain, first, the duration of the obstruction and mode of 
onset ; second, the possible cause of the obstruction ; third, the seat of the 
obstruction. The symptoms of intestinal obstruction depend upon the 
nature of the obstruction and the rapidity with which it has taken place. 
Constipation. In all forms of obstruction the one symptom is stop- 
page of the intestinal contents. When this takes place suddenly, and 
at the same time there is a local injury to the bowel, the symptoms, 
both local and general, are most pronounced and alarming. On account 
of the obstruction there is acute constipation, without the escape of flatus. 
Pain. For the same reason there is pain at the seat of obstruction. 
This occurs suddenly, and is intense aud lancinating in character, radi- 
ating from the point of obstruction. Over the part that is painful there 
is tenderness. Tumor. In many instances a tumor can be outlined due 
to single loops of intestine, thickened walls, or abnormal contents. 
This is particularly the case in the obstruction of invagination and the 
obstruction due to volvulus. Peristalsis. The obstruction further 
causes increased pe7*istalsis. This takes place above the point of con- 
striction. Sometimes the movements of the intestine can be seen through 
the abdomiual walls. Meteorism. The obstruction causes accumulation 
of gas above the point giving rise to meteorism. If the obstruction is 
low down, the distention and meteorismus are general. If high up, as 
in the small intestine, on account of constriction by Meckel's diverticulum 
or internal hernia, the meteorism is in the upper part of the abdomen, 
and may be limited in extent, or dilatation of the stomach alone may be 
present. Vomiting. Vomiting soon occurs in acute intestinal obstruc- 
tion due to decomposition of intestinal contents, to irritation of the 
stomach by the intestinal contents, to a trauma of the peritoneum at the 
seat of the obstruction, or, finally, to the occurrence of peritonitis. At 
first the contents of the stomach are ejected, then watery fluid, bile- 
tinged or largely made up of bile, and later faeculent matter. Although 
of fsecal-odor, true stercoraceous vomiting occurs later in the course 
of acute intestinal obstruction. It must not be forgotten that any 
obstruction of the intestine may accumulate with extreme rapidity, so 
that faecal vomiting may occur within two hours of the commencement 
of an obstruction. It is recognized by the odor of the matter vom- 
ited and by its color. It is a grave symptom, indicating complete 

36 



562 



SPECIAL DIAGNOSIS. 



obstruction of the intestine. Eructations of gas are frequent. The 
general symptoms are those of shock in its most pronounced form. Very 
rapidly the abdominal fades previously described develops. In a few 
instances, as in invagination, there may be fever, yet at once, or very 
soon in its course, the temperature falls to normal or subnormal, or 
remains at this point if it has not risen. The extremities are cold, the 
features pinched, the eyes sunken, the expression anxious. The pain 
causes the patient to double up in bed. The pulse becomes rapid, weak, 
thready in character, respirations proportionately hurried. The mind 
remains clear until the superveution of peritonitis and septicaemia. 

Chronic Obstruction. The symptoms are those of chronic constipation, 
with local symptoms due to the cause of the obstruction. The bowels 
are moved infrequently, and then in small amounts. In obstruction 
due to stricture from cancer, or cicatricial closure, the faeces are ribbon- 
shaped. Reference must again be made to the occurrence of diarrhoea, 
or the passage of small scybalous masses, on account of impaction of 
fasces. In chronic obstruction the general symptoms are those of inan- 
ition, with the nervous train of symptoms that have been described in 
constipation ; while the local symptoms depend upon the cause. When 
the local symptoms are due to the pressure of a tumor, or accumulation 
of pus or fluid within the abdomen, there is a history of the occurrence 
of local disease, on account of which the tumor developed; such history 
is obtained in fibroids or ovarian tumor, or in previous inflammation, 
which was followed by the occurrence of a tumor about the locality of 
the inflammation, as the pelvis or the appendix. 

If the obstruction is due to cancer of the intestine, the symptoms of 
that affection are present. A tumor can be made out at some situation 
in the course of the bowel. If the cancer is seated in the rectum there 
are tormina and tenesmus, and the discharge of blood and scybalous 
masses. Local examination reveals the presence of a malignant mass. 
Obstruction due to stricture from the healing of an ulcer is seated in 
the rectum or sigmoid flexure of the colon. Pain and a sense of obstruc- 
tion are referred to that locality. A history of syphilis can be obtained, 
and frequently the rectal tube, or finger, will detect the stricture. In both 
instances just mentioned there is a history of imperfect, irregular action 
of the bowels from time to time, with intervals of comparative comfort. 
These symptoms precede the constipation. When fasces accumulate 
in the colon the larger accumulations take place in the sigmoid flexure 
and in the caecum. Faecal tumors, described under Constipation, are 
felt through the abdominal walls. Obstruction from faecal accumula- 
tion is preceded by a history of constipation (q. v.). The accumu- 
lations generally can easily be discerned. It must not be forgotten that 
chronic intestinal obstruction may at any time become acute. 

Chronic intestinal obstruction always occurs in adults. The onset is 
gradual. Of the symptoms that attend obstruction of this form, pain 
is intermittent, and if there is faecal accumulation, is not very promi- 
nent. Vomiting occurs late in the disease, is small in amount, and gen- 
erally is not a prominent factor. Obstruction to the passage of faeces 
may be constant or alternate with diarrhoea. In faecal accumulation it 
becomes complete, although spurious diarrhoea may attend it. The dis- 



STOMACH, INTESTINES, AND PERITONEUM. 



563 



charges may be bloody, which points to cancer. Tenesmus is present 
in stricture low down in the large bowel. Meteorism is not marked 
when obstruction is high up, as in acute obstruction. When the 
obstruction is in the large iutestine it may be extreme, and in fsecal 
obstruction gradually increases as the obstruction becomes more 
marked. 

The forms of chronic obstruction that are attended by tumor have 
been mentioned previously. Coils of intestine in peristaltic movement 
are seen only in cases in which there is marked emaciation. 

Differential Diagnosis. When the symptoms of acute obstruction are 
present, it is essential to distinguish the form by ascertaining the nature 
of the obstruction, and determining, if possible, its seat. Varying fac- 
tors must be considered in order to estimate the cause of the obstruc- 
tion. Of these, first, the age. Obstruction from intussusception occurs 
early in life ; from bands or through apertures, in adult life, usually 
prior to forty years of age ; in volvulus, between forty and sixty. 
Obstruction due to a gall-stone occurs during the middle or later period 
of life — always after forty. 

Previous History. In obstruction by bands of adhesion there is a his- 
tory of peritonitis, or, as Treves points out, previous attacks of obstruction 
more or less marked. In volvulus the patient has been subject to con- 
stipation prior to the attack, and in intussusception there has been no 
previous history, unless polypus was present, causing dragging, colicky 
pains, and occasional discharge of blood. 

Symptoms. The symptoms of the various forms of acute obstruction 
vary somewhat. Pain in strangulation, from bands or hernia, is severe 
and paroxysmal in character, attended by collapse. It is also early in vol- 
vulus, though not as severe as in the former, and occurs at long intervals, 
becoming constant with exacerbations. In acute intussusception the 
pain occurs early, and is steady. It increases, and then may suddenly 
subside. At first it is paroxysmal, attending discharge of blood and 
mucus from the bowels. Local tenderness in the first group of cases 
occurs late. In volvulus it occurs early, and may be noted over dis- 
tended coils. In intussusception it is usually common about a sausage- 
shaped tumor. Vomiting is marked and occurs in strangulation, soon 
becomes fseculent, and increases the severity of the paroxysms of 
pain. In volvulus it does not come on so quickly, but is severe and 
constant when it takes place. The relaxation that attends vomiting 
often affords relief to the obstruction. In intussusception it does not 
occur as early as in the other forms, and is not so severe. It becomes 
fseculent in a small number of cases only. 

Constipation is continuous in all cases except intussusception. In 
the latter there is some constipation, but it is not absolute ; diarrhoea 
is not uncommon, and discharge of blood in the stools occurs in 80 per 
cent, of the cases, according to Treves. Prostration is severe in all 
cases, although probably not so marked in volvulus. Because of its 
close proximity to the rectum, tenesmus occurs in volvulus, and is of 
frequent occurrence in intussusception, often beginning early in the 
attack. 

Physical Signs. On palpation of the abdominal wall it is noted to 



564 



SPECIAL DIAGNOSIS. 



be soft and flaccid in most of the cases, unless peritonitis has ensued. 
This occurs early in volvulus, and rigidity is likewise marked. In a 
large number of cases a tumor can be made out in intussusception only. 
It is seated in the lower right quadrant of the abdomen. Early in the 
attack it is oblong and of sausage shape. When peritonitis ensues it 
disappears on account of the tympany. A portion of the gut may 
protrude at the anus, or be felt on rectal examination. Meteorism 
occurs about the third day in a strangulation ; it occurs early, is very 
rapid and pronounced in volvulus, and is absent in intussusception, 
unless constipation takes place. 

The Seat of Obstruction. The seat of obstruction is in a measure 
indicated by (1) the location of the pain, (2) the character of the swell- 
ing, (3) the character of the stools, (4) the degree of meteorism, and (5) 
the results of a rectal examination. In obstruction which occurs high 
up there is but little meteorism, the tumors are usually not detected, 
and pain is seated about the umbilicus or the upper quadrants of the 
abdomen. Obstruction that takes place at the ileo-csecal valve may be 
indicated by a tumor in the lower right quadrant over the region of the 
valve or just above it. It is usually at this point that invagination takes 
place, and hence we may look for tumor in this situation. On the 
other hand, volvulus of the colon, or stricture of the rectum, the 
obstruction being low down, is attended by much meteorism and pain 
in the left lower quadrant of the abdomen. In volvulus tumor may 
be detected in this position, and there is much meteorism. The position 
of the obstruction is sometimes indicated by the seat of peristalsis. This 
may be seen to stop at a given point, which usually indicates the position of 
the obstruction. In general it may be said, the more severe and rapid the 
symptoms the more likelihood that the obstruction is in the small intestine. 

The Urine. The position of the tumor, it is said, can be ascertained 
by changes in the urine. When the obstruction is in the small intes- 
tine, indican is much increased from the decomposition of albuminous 
substances and other products of putrefaction. In this location the 
urine may be suppressed. In stenosis of the large intestine it is not 
increased unless there should be cancer. 

Intussusception or invagination occurs most frequently in children 
prior to the tenth year. It is characterized by severe colic, and pain in 
the abdomen, first complained of about the navel. The severity increases 
in paroxysms, and only lessens if complete strangulation has taken 
place. With the onset of the pain there are one or two movements of 
the bowels which contain mucus and blood. After this there may be 
constipation, or the stools continue to be loose, and are as frequent as 
fifteen or twenty in a day. Sometimes they are quite bloody, and 
almost always there is some tenesmus. In a short time after the attack 
vomiting commences. It may be constant or occur only after taking 
food. At first the abdomen is soft, but tender on pressure. A sausage- 
like tumor may be felt on the right side below the transverse umbilical 
line. On inspection of the rectum a portion of the intestine may be 
seen, dark and gangrenous in appearance, or it may be felt by palpation. 
If there is much tenesmus, the anus often remains open. In rare cases 
the bowel may slip back and the symptoms subside spontaneously. 



STOMACH, INTESTINES, AND PERITONEUM. 



565 



On the other hand, peritonitis may rapidly ensue, with high fever, fol- 
lowed by collapse and death. 

Diagnosis. It must be distinguished from the entero-colitis of child- 
hood, or the proctitis due to a polypus. In entero-colitis there is no 
tumor, and the collapse and prostration do not occur so early, and are 
not so rapid. There is greater likelihood of a number of the stools 
being greenish, like spinach. In a polypus of the rectum the symp- 
toms are local, the child is worn out and restless, but great abdominal 
tenderness, and the tumor, meteorism, vomiting, and collapse do nut take 
place. The rectum must be examined. 

Intussusception must be distinguished from peritonitis in which 
symptoms of stenosis of the bowel from ileus paralytica may be 
present. The history and sequence of events must be watched care- 
fully. Often the commencement of the affection about hollow viscera 
which have previously been the seat of disease, or its onset with 
sudden perforation, will point to the nature of the affection. In peri- 
tonitis there is no active peristalsis ; there is general distention of the 
abdomen, with general tenderness ; the urine is diminished, but does 
not contain indican in excess. Collapse ensues rapidly. Signs of 
effusion within the abdomen may appear. 

Course of Hernia and Volvulus. Obstruction due to these condi- 
tions occurs in adults after the fortieth year of age, usually in both 
sexes. In stricture from the pressure of bands there has usually been 
a history of previous attacks of peritonitis or of inflammation of the 
structures in relation to the peritoneum. The attack begins suddenly, 
and the symptoms may from the start be most pronounced. They are 
the typical symptoms of intestinal obstruction previously described. 
The local tenderness, however, may not be present as early as in other 
forms of obstruction. It is quite characteristic, however, to be unable 
to find a tumor or positive local cause for the obstruction, also not to 
have meteorismus. This is due to the fact that the obstruction is 
usually high up in the intestinal tract. 

Volvulus. Volvulus occurs most frequently in males. It occurs 
late in life, and is usually preceded by a history of constipation. 
Premonitory symptoms may have been present for a few days, but the 
symptoms of obstruction take place suddenly. They are the symp- 
toms of acute obstruction, but as the lesion is in the lower portion of 
the bowel meteorismus is present to a marked degree, and rectal symp- 
toms are found. Tenesmus is present in a small proportion of the cases. 
Peritonitis is likely to set in early with increase in the temperature, 
increase in the tenderness of the abdomen, and more pronounced 
symptoms of collapse. 

Diagnosis of Intestinal Obstruction. Intestinal obstruction 
must be distinguished from peritonitis and appendicitis. This is some- 
times very difficult. Careful attention must be paid to the evolu- 
tion of the case and the history of previous abdominal disease, or of 
lesions on account of which, on the one hand, peritonitis may occur, 
or on the other, obstruction of the bowel. In peritonitis the attack 
follows disease in the uterine appendages, the vermiform appendix, 
or the gall-bladder ; or from perforation in some portion of the gastro- 



566 



SPECIAL DIAGNOSIS. 



intestinal tract. Fever usually attends the inflammation, with or with- 
out a chill. Vomiting will probably occur at the onset, and then subside 
until the peritonitis becomes general. The first paroxysms of vomit- 
ing are apparently due to shock. The vomiting that occurs rarely be- 
comes fseculent. As the peritonitis advances it is not an active action, 
but instead a passive one ; a simple constant regurgitation of a large 
amount of fluid, greenish or grayish-yellow, or watery, takes place. It 
pours into the mouth, and is simply discharged without the occurrence 
of retching. The abdomen is swollen and tympanitic. The symp- 
toms due to excessive tympany are more marked than in intestinal 
obstruction. The diaphragm is interfered with, breathing is hurried. 
It is tender on pressure and is the seat of general pain. The gen- 
eral pain and tenderness, however, can usually be found to be more 
marked at some one of the situations which is the primary focus of the 
the disease. Further, on local examination, in these positions fulness 
or undue prominence or swelling may be observed. On palpation over 
the point of origin there may be localized oedema. The symptoms of 
collapse do not differ from those of intestinal obstruction in marked 
degree, although the peculiar appearance of the face and other nervous 
features occur more rapidly in peritonitis than in obstruction. It must 
be remembered that peritonitis in a large majority of cases attends 
obstruction. 

In appendicitis the symptoms are somewhat like those of intestinal 
obstruction. There may be constipation, and the occurrence of vomiting. 
The former is not pronounced, and can usually be relieved. Vomiting 
subsides after the first twenty-four hours, unless peritonitis supervenes ; 
it is never stercoraceous. The local physical signs are characteristic. In 
appendicitis there is fixed tenderness on pressure at McBurney's point. 
Some swelling can almost always be observed. On light or deep per- 
cussion there is change in the note as compared with the other side. 
Fluctuation can often be detected in from two to four or five days. 
Both the tumor and fluctuation can be detected by bimanual examina- 
tion of the abdomen and flank. Examination by the rectum may 
reveal a tumor at the brim of the pelvis on the right side. Fever 
attends the attack throughout. When peritonitis supervenes there is 
rigidity of the entire abdomen, which at first was localized to the right 
lower quadrant. 

Intestinal obstruction must not be confounded with enteritis. In all 
forms there is diarrhoea, in many vomiting. Pain of a colicky nature, 
spreading from the neighborhood of the umbilicus, is marked when- 
ever obstruction to the passage of faeces or gas takes place. Vomiting 
is not stercoraceous, aud the general symptoms, collapse, etc., do not 
occur. Acute hemorrhagic pancreatitis is also attended by symptoms 
similar to those of intestinal obstruction. There is sudden severe pain 
in the upper half of the abdomen, with vomiting, and the rapid devel- 
owment of collapse ; there may be constipation ; the situation of the 
pain is of some significance. Vomiting never becomes stercoraceous, 
flatus can usually be passed and the bowels opened by an enema. 
Meteorismus does not take place. If the symptoms are not too severe 
there may be increased dulness, and possibly a tumor on deep palpa- 



STOMACH, INTESTINES, AND PERITONEUM. 



567 



tion iu the left upper quadrant of the abdomen along the margins of 
the ribs, which should be dull on percussion, or, on account of its rela- 
tion to the stomach, give a dull tympanitic note. The symptoms of 
internal hemorrhage are present, pallor of the face and extremities, 
syncope, and in addition prostration and other symptoms of collapse. 

Appendicitis. 

This is by far the most important affection of the intestinal tract. 
It is of frequent occurrence compared with intestinal obstruction, and 
if recognized is amenable to relief in a very large percentage of the 
cases ; whereas intestinal obstruction is frequently fatal. We see 
twenty-five cases, at least, of appendicitis in all forms to one case of 
any form of obstruction. Its importance, therefore, is readily recog- 
nized. Appendicitis occurs most frequently in the young — in the large 
proportion of cases under thirty. I have seen it as early as two 
years of age, although from the fifteenth to the thirtieth year it is more 
frequent than at any other period. The symptoms vary, but clinically 
may be divided into those of appendicitis without perforation and 
appendicitis with perforation. Appendicitis without perforation is 
characterized by relapses, and is known also as recurring appendicitis. 

Appendicitis without Perforation. There are probably cases 
of catarrhal appendicitis, although I am not prepared to say that 
catarrhal inflammation of the appendix gives rise to marked local 
symptoms, for in cases on the post-mortem table in which the lesions 
of catarrh were found, there had not been any symptoms during life 
due either to intestinal catarrh, or to any symptoms pointing to appen- 
dicitis in any form. Moreover, many cases in which the attacks of 
appendicitis had been slight finally come to an attack with perforation. 
In these cases of the lighter attacks, if operative measures are resorted 
to during the interval, they are always found to contain a fluid loaded 
with micro organisms which are capable of causing purulent inflamma- 
tion, as the staphylococcus or streptococcus. Clinically, therefore, all 
forms of appendicitis should be considered due to purulent inflamma- 
tion, with, on the one hand, escape of the contents into the bowel, and 
natural relief of the symptoms ; or, on the other, complete obstruction 
with perforation. In recurring appendicitis in which the appendix was 
removed during the interval, I have always found pus or a muco- 
purulent material which was charged with streptococci or staphylococci, 
as well as the bacillus coli communis, natural to the intestinal canal in 
this region. 

Symptoms of the Attack. After exposure to cold rarely, fre- 
quently after an indiscretion in diet, the patient is seized with pain, 
referred to the right lower quadrant of the abdomen. It is paroxys- 
mal in character, increasing in intensity, and may be complained of as 
colicky. The pain is usually such as to require the patient to take to 
bed and attempt to secure relief by local applications. The severity of 
the pain may be such as to require the treatment previously noted, or 
only of such degree that the patient pays but little attention to it. He 
even may go about his business during the time and seek professional 



568 



SPECIAL DIAGNOSIS. 



advice at the office of a physician. It is this class of cases that are 
attributed to ordinary cholera morbus or intestinal indigestion. It may 
be moderately severe only, particularly if there is diarrhoea. With the 
onset of the pain vomiting usually occurs. At the same time the bowels 
may be opened, or they may be confined. Vomiting may not occur if 
there is diarrhoea. Vomiting is usually attended by some nausea, 
although this is not marked. The vomiting is complete, there is no 
retching. It occurs at intervals, between which there is comparative 
comfort. The contents of the stomach are ejected, and then mucus. 
If the patients are to get well, vomiting does not return unless excited 
by food. If peritonitis supervenes in the course of three or four days 
vomiting returns. The patient lies on his back with the right leg 
flexed. 

Even with a mild degree of pain, the skin is hot and the tem- 
perature slightly raised. In the cases in which the pain is more 
severe the general reaction is greater. The temperature rises rap- 
idly to 102° to 103°. The skin is hot and dry, the face flushed. 
The pulse in a young adult rises to 90 and 95. It is full and 
strong. On account of the pain there is some restlessness. In some 
cases the patient complains more of the fever than of the pain after 
the first severity of it has subsided. The tongue is coated; appetite 
is lost. 

On physical examination the area which was the seat of pain is tender. 
When examined with the tip of the finger pressing firmly, a point 
of more marked tenderness can usually be found on a line midway 
between the anterior superior spine of the ilium and the umbilicus. It 
is known as McBurney's point, and is most characteristic. It is due to 
tenderness elicited over the site of the appendix. On inspection the 
affected area is slightly or may be considerable enlarged. Comparison 
must be made with the opposite side. It will be seen that the usual 
depression in front of the anterior spine, or the cavity toward the loin, 
is not as deep as on the opposite side. In front the surface may be 
even with the plane of the ilium. On palpation, in addition to tender- 
ness and pain at the point previously indicated, fulness and enlarge- 
ment can be distinguished. There is resistance to pressure and more 
or less rigidity of the abdominal muscles. On careful measurement the 
semi-circumference will be found in most instances to be larger than 
the semi -circumference of the opposite side. When bimanual palpa- 
tion is performed, the left hand being placed in the loin behind and the 
right over the abdominal surface, resistance, induration, and rigidity 
can more easily be detected. On percussion there is change in the note 
compared with that of the opposite side, and change in the percussion note 
during the course of the disease. This is particularly the case if the 
symptoms go on to perforation. On careful deep percussion a dull 
tympanitic tone is elicited, or a distinct area of dulness can be mapped 
out, but in some instances the distended caecum yields tympany which is 
greater than on the opposite side. 

The pain is usually referred to the region above mentioned. It 
may, however, be referred to the bladder or genitals, and be attended 
with vesical tenesmus and frequent micturition. The character of the 



STOMACH, INTESTINES, AND PERITONEUM. 



569 



pain and the bladder symptoms are such as to simulate an attack of 
renal colic, with the passage of sand. On account of the locality of 
the pain it may be attributed to the Fallopian tube or ovary and 
thought to be due either to pain on account of disease of these organs 
or to dysmenorrhea. It is not likely to be mistaken for the pain 
of dysmenorrhoea if the patient is subject to pain at the usual monthly 
period. If, however, the physiological and pathological affection should 
take place at the same time or the latter occur about the time of the 
monthly period a mistake in diagnosis may occur, particularly as in- 
creased abdominal pain may cause a uterine discharge. The occurrence 
of fever would exclude dysmenorrhoea in cases in which this symptom 
was present. The pain and leg flexion simulate hip-joint disease. 

After the first twenty-four hours, during which the above-mentioned 
symptoms described take place, the fever continues. There is anorexia, 
but vomiting occurs at longer intervals if at all. The local symptoms 
continue, although modified usually by methods of treatment which are 
applied. Both general and local symptoms frequently subside after a 
free movement of the bowels is secured, which occasionally takes place 
spontaneously. In other cases they continue a week or ten days, and 
may even extend over a longer interval of time. 

After five or six days at the furthest, fever subsides, the local disten- 
tion lessens, the paroxysms of pain disappear, and convalescence ensues. 
There may, however, be localized tenderness for a considerable period 
of time, and diarrhoea, or at least two or three evacuations each day, 
for a week or more. In rare instances peritouitis supervenes without 
the occurrence of perforation. The onset under these circumstances is 
more gradual, but the symptoms are like those of peritonitis under 
other circumstances. Infection takes place directly through the ap- 
pendix. 

When the fever continues, with mild diarrhoea, intestinal pain, and 
flatulency, the case may be mistaken for typhoid fever. The tem- 
perature is, however, more remittent in character in the former, and 
the diarrhoea is not characteristic of the latter. The eruption of 
typhoid does not occur, and the symptoms of the typhoid state do not 
ensue. The diazo reaction may aid in forming a conclusion. The 
occurrence of bronchitis and other symptoms of typhoid would point 
to the true disease. 

Recurrent Appendicitis. Frequent attacks of mild appendicitis 
occur; they may occur as frequently as every three months, or the 
interval may be as long as a year. The attacks are similar to the 
attacks just described. The local symptoms in some instances are more 
marked, because there has been a localized peritonitis previously. The 
induration is greater, and dulness is more characteristic. In some 
instances the attacks are comparatively mild, continuing but twenty-four 
hours, and are described as attacks of colic. Often they have been 
treated by the patient himself, or by household remedies alone. The 
patient spends a night in agony with cramps, but the next day follows 
his usual habits. It is possible that there has been no fever with the 
attacks, but in all cases of appendicitis which I have seen fever has 
been a constant accompaniment. 



570 



SPECIAL DIAGNOSIS. 



Appendicitis with Perforation. Before perforation takes place 
tlie patient may have had symptoms of the mildest form of appendicitis 
for two or three days, or it may have extended over a long period of time, 
with the expression of colicky pains alone. Not being under observa- 
tion, the presence of fever cannot be utilized as a diagnostic feature. 
The perforation may take place early in the course of an acute attack. 
After the characteristic symptoms of appendicitis just described, in their 
most intense degree, the symptoms of peritonitis set in. The abdomen 
rapidly becomes distended, the characteristic vomiting ensues, and col- 
lapse develops. Perforation under these circumstances has occurred 
within the first twenty- four hours, or at least has not been postponed 
beyoud forty-eight hours. Local inflammation about the appendix does 
not take place, and the local signs of an inflammatory tumor are not 
present, although tenderness at the special point can be elicited. If the 
perforation is more gradual, and there has been time for the occurrence 
of local inflammation about the appendix, by which pus is prevented 
from infecting the peritoneum, or if perforation takes place behind in 
the connective tissue which surrounds the mass, in which situation there 
is always inflammation, the local signs of the abscess or inflammatory 
tumor occur. There is swelling of the affected side, the normal outline 
is effaced. The area is indurated, and although the early pronounced 
rigidity gradually gives way to a boggy sensation, oedema of the surface 
of the skin appears. This can be elicited by pressure on parts that are 
hard and resisting, as the spine of the ilium. Fluctuation can often be 
detected by bimanual palpation. Dulness is found, although in some 
instances it may be very slight, scarcely an appreciable change in pitch. 
Both light and deep percussion must be performed, and compared with 
the results of percussion in the opposite region. Examination per rectum 
may yield immediate results. An induration may be felt about the 
brim of the pelvis or the rectal fossa, which fluctuates and may eventu- 
ally soften. With the finger in the rectum, and pressure above, better 
results may be obtained. If the symptoms of peritonitis do not arise, 
or rapid infection of the system take place, the signs of abscess become 
more and more marked. The surface becomes reddened, and pointing 
may take place toward the groin or opposite the spine. Sometimes the 
swelling increases in the direction of the loin, and the abscess may point 
in that situation. 

As the abscess develops the general symptoms change. They now 
become the symptoms of suppuration. The fever is remitting or inter- 
mitting. There may be chills. Sweats are common, and there is loss 
of appetite and the occurrence of diarrhoea. In former times it was 
customary to see abscess develop in some other situation, or symptoms 
occur from burrowing of the pus in various directions. It may extend 
upward along the back of the colon, underneath the diaphragm, and from 
thence to the pleura and lung, and be expectorated. The abscess may 
open into the rectum or into the bladder. If the local inflammation is 
virulent and the symptoms are intense, if peritonitis has not taken 
place, the symptoms of septicaemia may rapidly ensue. This sometimes 
may occur quite early in the disease. There may be vomiting and 
septic diarrhoea, and a slight delirium at night. An excessively rapid 



STOMACH, INTESTINES, AND PERITONEUM. 



571 



and feeble pulse is seen; in one instance seen it was irregular. Extreme 
prostratiou ensues, followed by the symptoms of the typhoid state. 

It is clear that in cases of appendicitis we must attempt to recognize : 
(1) the inflammation before perforation has taken place; (2) the occur- 
rence of perforation ; (3) the occurrence of peritonitis due to either of 
the two conditions; (4) the occurrence of abscess (paratyphlitis and 
perityphlitis); and (5), the occurrence of septicaemia. 

Typhlitis is an inflammation of the caecum due to accumulation of 
faeces or foreign substances. It may be due to ulceration The inflam- 
mation may remain as a localized enteritis, or may be followed by ulcera- 
tion. In the majority of cases the ulceration is due to pressure by the 
contained foreign material or faeces. The inflammation occurs in early 
life usually. The patients have been subjected to constipation. The 
attack may follow some error in diet. There is pain in the right iliac 
fossa, constipation, and the occurrence of nausea. Moderate fever de- 
velops. On examination there is fulness in the right iliac region, and 
the right thigh may be flexed, the part is tender to pressure, and a 
doughy, sausage-shaped tumor may occupy the region of the caecum. 
The more severe symptoms last two or three days. Local tenderness 
may continue a week or even longer. The tumor gradually disappears. 
If ulceration takes place, inflammation about the caecum ensues. An 
abscess forms gradually in the flank behind. Perityphlitis is the term 
applied to this secondary abscess, although, as the term has been con- 
fused with paratyphlitis it had better not be used in this connection. 

Appendicitis must be distinguished from perinephric abscess and 
the abscess which follows perforation of the intestine or caecum at this 
point. Perinephritis can scarcely be distinguished unless there has 
been a previous history of renal calculus and pronounced evidence of 
disease of that organ preceding the formation of the abscess. Pericecal 
abscess follows the stercoral typhlitis which occurs as the result of 
cancer in the course of the large intestine. The history of their con- 
ditions point to the true nature of the disease. Abscess may occur 
behind the caecum in cases of caries of the vertebrae and in some rare 
instances of empyema in which it has dissected downward. Hip-joint 
disease must be distinguished from appendicitis. The leg is flexed, 
the patient complains of pain about the region of the hip ; unless 
-careful observation has been made in the beginning of the attack the 
early march of appendicitis may not be recognized. The two are con- 
founded after abscess formation The flexed leg of appendicitis can be 
-extended under ether, and examination then shows the joint to be free 
from disease. 

Feuwick says that acute tubercular peritonitis may be confounded with 
perforation of the appendix. There are pain and tenderness in the hypo- 
gastrium, dulness on percussion, and fever. In tubercular peritonitis 
the onset is more gradual, the pain and tenderness more general, there 
is no distinct tumor or increased tension in the hypogastrium. If there 
is dulness on percussion, the line generally varies with the position of 
the patient. Diarrhoea is urgent, and there are, in most cases, some 
signs of consolidation of the lungs. The absence of tumor in the right 
iliac region and in front of the rectum is the chief point; for when 



572 



SPECIAL DIAGNOSIS. 



perforation occurs in phthisical subjects there is generally very slight 
pain, and severe diarrhoea is often the only prominent symptom. 

Abscess about the head of the caecum is due (1) to appendicitis, of 
which sufficient mention has been made; (2) to perforation of the 
caecum on account of typhlitis ; (3) to perforation on account of cancer 
of the intestine; (4) abscess secondary to kidney disease, perinephritic 
abscess ; (5) to abscess secondary to disease of the vertebrae. The physi- 
cal signs are those of abscess due to perforation of the appendix. The 
symptoms are the local symptoms of abscess and the general symptoms 
of suppuration. 

Tuberculosis of the Intestine. 

The disease is usually secondary to chronic tuberculosis, but may be 
primary, especially in children. The symptoms are usually those of 
diarrhoea, and in the primary form this is associated with general ema- 
ciation, which advances rapidly, and with anaemia. Fever of the inter- 
mittent or remittent type is present. There is meteorism ; the abdomen 
is much distended, but eventually becomes contracted. The mesenteric 
glands can be made out along the spinal column, and the intestines may 
become bunched into a mass, yielding a dull tympany on percussion in 
the centre of the abdomen. The diarrhoea is attended with colicky 
pains. The diagnosis is based upon the rapid emaciation, irregular 
fever, enlargement of the mesenteric glands in a patient, usually a child, 
who had probably been exposed to tuberculous infection. In one of 
my cases the child, aged four years, ate of the same food, using the same 
utensils, as a brother, a lad of twenty-two, dying of pulmonary tuber- 
culosis. The child was constantly with the brother. The remainder 
of the family, eight in number, remained in perfect health, and were 
all of good physique. The brother became infected by association with 
tuberculous subjects in improper quarters away from home. 

Cancer of the Intestines. 

The disease usually occurs late in life, and is associated with 
progressive emaciation and cachexia. There may not be any symp- 
toms save general failure of health until the sudden occurrence of 
obstruction of the bowel. The symptoms vary with the position of 
the carcinoma and the direction of growth of the tumor. In some 
instances with the general symptoms there may be irregular pain in the 
abdomen, with irregularity of the stools. The tumor may be detected 
if the small intestine is involved. Its detection is facilitated by having 
the patient get on the hands and knees, palpating the abdomen in this 
position. If the tumor is seated in the lower colon, pain in the sacral 
region, resembling sciatica, may be complained of ; if the caecum or 
the sigmoid flexure is the seat of disease a tumor is usually detected. 
Wherever the situation, the tumor found is tender, usually lying in the 
axis of the intestine — movable if in the small intestine, fixed if in the 
caecum or the sigmoid flexure. In the latter location the tumor may 
be felt per rectum. One notable characteristic is that it may be pal- 
pable some days and not be present at other times. The position and 



STOMACH, INTESTINES, AND 



PERITONEUM. 



573 



size may vary from day to day, although it is always hard and knotty, 
not doughy. Constipation is characteristic of most of the cases. It may 
alternate with diarrhoea. The stools are frequently ribbon-shaped, or 
they may pass in scybalous masses, or large or small amounts of blood, 
chiefly the latter, are passed with pus or mucus ; sometimes masses 
resembling caucer can be found in the stool. If the tumor is in the 
rectum there is great difficulty iu defecation ; the act is attended by 
pain. Later the pain becomes constant, and may radiate to the hip or 
the genitalia. Sometimes this pain is the only symptom complained of. 
Mucus and blood appear in the stools, the bowels being alternately 
confined and loose. Paralysis of the sphincter ani may take place with 
incontinence. A tumor may be felt per rectum or be seen through the 
speculum. It may be a hard knotty mass. 

The diagnostic symptoms are : (1) The general symptoms of cancer. 
(2) The tumor. (3) The occurrence of constipation which leads to 
complete obstruction, or obstipation, alternating with diarrhoea. Blood 
in the stools, with alteration in the shape of the faeces, is significant. 

Amyloid Degeneration of the Intestines. 

The symptoms are those of diarrhoea, persistent but mild in character, 
associated with symptoms of amyloid disease in other organs. With 
enlargement of the liver and spleen, changes in the urine due to amyloid 
disease are present. The occurrence of these symptoms in a patient 
with syphilis, or especially in a child with bone disease or tuberculosis, 
points to the nature of the case. 

Infarction of the Bowel. 

The symptoms take place suddenly. The patients have reached 
middle or late life, and have atheroma of the general arterial system. 
Sudden pain in the abdomen, with vomiting and symptoms of collapse, 
takes place. Moderate obstruction occurs with distention of the abdo- 
men. After the pain diarrhoea sets in with the passage of blood. The 
age and the absence of tumor distinguish it from intussusception, the 
only intestinal condition with which it may be mistaken. 

Dilatation of the Colon. 

The dilatation takes place temporarily in constipation with obstruc- 
tion. In rare cases it may become permanent. The distention of the 
abdomen is enormous. It may begin in childhood and continue 
through adult life. Congenital obstruction ; the eating of oatmeal or 
similar food, with attendant constipation, leads to distention. The 
bowels are constipated. The constipation may continue for several 
weeks, during which period there is increasing dulness in the tract of 
the colon, with faecal tumors distinguished by palpation. The constipa- 
tion is relieved by diarrhoea, which may continue for two or three days, 
during which enormous amounts of faeces are passed. It may be pre- 
ceded by vomiting of faecal character. After the bowels are open the 
distention continues, the dulness being replaced by tympany. 



574 



SPECIAL DIAGNOSIS. 



Diseases of the Rectum. 

Consideration of rectal lesions belongs to the surgeon. It is proper^ 
however, to insist upon the very frequent deleterious effect of such 
lesions in neurasthenic subjects. Indeed, the bleeding which attends, 
hemorrhoids may be sufficient to lead to profound anaemia, upon 
which neurasthenia may readily develop. The local suffering due 
to rectal fissure, or prolapse, may aggravate any tendency to the 
state of neurasthenia, or aid materially, with other conditions, to more 
firmly fasten it upon the system. In cases of anaemia, of neurasthenia, 
of the gastric neuroses, of debility, or prostration, the cause of which 
cannot be ascertained, the rectum should be examined. The appear- 
ances of hemorrhoids and other rectal affections are described in works 
on surgery. Hemorrhoids, ulcers, fistula, and carcinoma are to be 
sought for in abdominal affections. 

Inspection and palpation are necessary. The symptoms are those of 
local pain, tenesmus, and frequently hemorrhage. The pain follows a 
movement of the bowels. There may be a feeling of a foreign body in 
the rectum, with some itching and burning about the anus. The pain 
may be so severe as to inhibit defaecation. The timid subjects will not 
endure the act ; in cousequence they suffer from vertigo, headache, 
tympanites and symptoms of gastro-intestinal disorder. In some in- 
stances there is chronic catarrh of the rectum with discharge of small 
stools containing mucus or pus streaked with blood. Cases occur in 
which hemorrhage is the only symptom, the constant recurrence of 
which leads to grave constitutional effects. Hemorrhoids are the 
lesions for which the rectum is most frequently examined. They, as 
well as other lesions, are of diagnostic significance in affections beyond 
the rectum. Thus, in all forms of portal congestion, internal hemor- 
rhoids are of frequent and constant occurrence, and when found in 
the toper may be one of the first indications of cirrhosis of the liver. 
Rectal fissure is not of much diagnostic significance. The finding of a 
small cancer, the symptoms of which may be those of hemorrhoids, may 
explain emaciation and the development of cachexia. Ulcer of the 
rectum may be due to syphilis, cancer, or tuberculosis. A fistula is 
often tuberculous. The rectum must be examined in cases of pyaemia, 
particularly of the portal variety, when jaundice, enlargement of the 
liver, and hectic are present. Local rectal disease may cause pyle- 
phlebitis. 

Diseases of the Peritoneum. Peritonitis. 

Inflammation of the peritoneum may be acute or chronic. It may be 
general or localized. Acute inflammation is rarely primary ; it may 
occur in the later stages of chronic Bright's disease, or other dyscrasia, 
without apparent cause. If it follows exposure to cold, or trauma, it 
is called traumatic peritonitis. It is due in the large majority of cases 
to extension from organs which the peritoneum covers, or to perforation 
of one of the abdominal organs. In the first instance it may follow 
inflammation of any portion of the gastro-intestinal tract, of the pelvic 



STOMACH, INTESTINES, AND PERITONEUM. 



575 



viscera, and suppurative inflammation of the spleen and liver, and of 
the pancreas. In all instances the primary inflammation in the organs 
mentioned is due to some micro-organism, as the staphylococcus, the 
streptococcus, or the bacillus coli communis, and the peritoneal inflamma- 
tion to extension of the infection. In a peritonitis that occurs from 
perforation, the element of infection also plays an important part, as 
in ulcer of the stomach or bowels. In inflammation of the gall-bladder 
perforation may take place with resulting peritonitis. Abscess in the 
liver, spleen, or kidneys, bursting into the peritoneum, also leads to 
general peritonitis. The most common forms, however, are due to 
appendicitis or disease of the Fallopian tubes. Acute peritonitis may 
also occur in cases of tuberculosis by direct infection. 

Symptoms. The onset of acute peritonitis depends in a measure 
upon the cause. When there is perforation or infection the onset 
is sudden ; chilly feelings or a rigor occur with intense pain in the 
abdomen. If at first localized the pain rapidly becomes general, is con- 
stant aud increases in exacerbations, is very intense, aggravated by move- 
ments and by pressure. The patient lies on the back with the legs 
drawn up. The dorsal decubitus is assumed in order that the tension of 
the abdominal muscles may be relieved. The location of the pain depends 
upon the seat of primary infection ; this is usually in the right or left 
lower quadrant, more marked about the tubes or the appendix. In 
perforation of an ulcer of the stomach the pain may be complained of in 
the back, or referred to the chest or the shoulders. 

Physical Examination. On palpation the abdomen is extremely 
sensitive. The patient is unable to bear the weight of clothing or 
external applications. The abdomen gradually becomes distended, 
and on percussion is tympanitic. The distention may become so great 
as to push up the diaphragm and interfere with the respirations, so that 
they are shallow ; and dislocate the heart so that the apex beat is 
seen in the fourth interspace. The splenic dulness may be obliterated 
entirely and the liver dulness reduced. It is said that in some instances 
this may be obliterated, although recent observations affirm that such 
obliteration only occurs in the anterior portion of the abdomen. Liver 
dulness persists in the axillary region, though diminished in extent. 
This obliteration could only take place in perforative peritonitis. Osier 
points out that in pneumo-peritoneum, perforation may obliterate the 
hepatic dulness, although dulness in the lateral region continues on 
account of the effusion of fluid. If a patient with gas in the peritoneum 
is turned on the left side a clear note is heard beneath the seventh and 
eighth ribs (hepatic region). The abdominal muscles are often rigidly 
contracted. In some cases, usually when the inflammation is due to 
the streptococcus, there is not much distention of the abdomen, or it 
may be flattened entirely with board-like rigidity. In these instances 
pain is not so marked, and tenderness may not be complained of. 

The respirations are hurried and the superior thoracic type of breath- 
ing is seen because the action of the diaphragm is painful. The act of 
speaking or coughing increases the pain, and the patients are unable to 
take a full breath without suffering. With the occurrence of pain and 
local signs, vomiting usually sets in. It is painful and at first is com- 



576 



SPECIAL DIAGNOSIS. 



plete, the contents of the stomach being ejected and then a yellowish 
bile-stained fluid ; later the vomit becomes greenish in color. Complete 
vomiting is displaced by simple regurgitation of fluid, so that on the 
slightest motion of the patient, or on taking a small amount of fluid, 
the characteristic greenish-colored fluid is regurgitated without action of 
the diaphragm. This may for twenty-four to forty-eight hours be 
almost continuous. The tongue is moist and furred early, but later 
becomes dry and often is cracked and red. The bowels are constipated. 
They may be loose at first, but constipation is characteristic. The in- 
testines are paralyzed from overdistention and from oedema of the walls 
due to inflammation. 

The general symptoms are marked. After the chill the temperature 
rises to 104° or 105°. In septic cases it continues at this point, or may 
rise to a greater height. If cases progress rapidly a temperature of 
105° or 10ti° on the second or third day is not uncommon. In other 
cases after the initial rise the elevation subsequently is not so great, but 
there is not much difference between morning and evening temperature 
unless there is an abscess. 

The urine is scanty; micturition may be frequent and painful, particu- 
larly if the inflammation began in the pelvic organs. The urine usually 
contains a large amount of indican in the suppurative form. 

The appearance of the patient at the height of the disease is character- 
istic. The expression is anxious, the face is pinched, the eyes sunken. 
Vomiting causes wasting. The collapse is marked, with the character- 
istic facies previously described (see Expression). The pulse is rapid 
and feeble and soon becomes thready, ranging from 110 to 150. In 
the first stages it may be small and hard. Attention has been called 
frequently to the peculiar wiry pulse of the early stage of peritonitis. 

In severe cases death may take place in thirty-six to forty-eight 
hours. Usually a fatal termination does not take place for five or six 
days, and it may be longer. The vomiting persists, collapse with fall- 
ing temperature ensues, the pulse becomes rapid and thready. Through- 
put the entire attack, unless symptoms of septicaemia are marked, the 
mind is clear. The patient dies of paralysis of the heart. Septicsemic 
symptoms are indicated by a dusky color of the face, rapid and irregu- 
lar pulse, slight delirium, dry brown tongue and other evidences of the 
typhoid state. 

If the cases are prolonged some effusion may take place into the 
peritoneal cavity. Dulness is noted in the flank, and if it is possible to 
move the patient it alters the position. If recovery takes place, par- 
ticularly in tuberculous cases, the affection may become circumscribed 
and be indicated by dulness which is not movable. 

Diagnosis. It is essential in making a diagnosis to ascertain, if 
possible, the primary source of the infection or inflammation. Inquiry 
in order to determine this is made with regard to the age, sex and 
history of previous disease of the patient. In young adults appendicitis 
is first to be thought of ; in females inflammation of the pelvic organs. 
In chlorotic subjects, if the pain is high up, the history of ulcer of the 
stomach must be inquired for. Later in life, particularly if there has 
been jaundice, the history of frequent attacks of gall-stones and of 



STOMACH, INTESTINES, AND PERITONEUM. 



577 



hepatic disturbances must be ascertained. All forms of intestinal 
obstruction must be sought for. Frequently, however, a definite cause 
cannot be ascertained. If it occurs in the course of typhoid fever it is 
usually due to perforation, but the occurrence of pain may not be com- 
plained of on account of the mental state of the patient. Under other 
circumstances the symptoms cannot be overlooked. 

Acute peritonitis must be distinguished from entero-colitis. The 
distinction is not usually difficult to recognize if attention is paid to 
the development of the case. The pain is not so severe in entero- 
colitis ; it is more colicky in character. The general tenderness is not so 
great as in peritonitis, and the distention does not interfere with respira- 
tion to such a marked degree. Diarrhoea is more common in entero-colitis ; 
collapse is not so pronounced if present. Obstruction of the bowel. The 
diagnosis is difficult in the absence of a distinct history, but in peritonitis 
we do not have stercoraceous vomiting. The tympanites is more general, 
the pain is more general, and the vomiting is different unless the peri- 
tonitis is due to obstruction. A tumor, if present, may point to the true 
nature of the case, and if there is any discharge from the rectum,- 
invagination may be the exciting cause. 

Peritonitis is simulated by a condition to which the name hysterical 
peritonitis has been applied. It occurs in hysterical subjects, and in 
every feature the true form is imitated. The mode of onset, the decu- 
bitus, the difficulty in micturition, and the local distention and tenderness 
of the abdomen are characteristic of both. In a few cases which we have 
seen the vomiting is not of the nature of true peritonitis, either in the mode 
of ejection or the character of the fluid. It must not be forgotten that 
even the temperature may be elevated and collapse take place in the 
hysterical form. In the cases which I have seen the abdominal facies 
does not develop, while, on the other hand, the facies of hysteria, with 
the self-interest which the patient exhibits and the precision with which 
symptoms are narrated, coupled with emotional or other manifestations 
of hysteria, point to the true nature of the affection. Other symptoms 
of hysteria may arise. The case is judged by the history of these asso- 
ciated manfestations and the permanent stigmata of the disease. There 
is always a positive absence of cause, and of disease in any of the 
abdominal viscera. Sometimes in these cases if the attention of the 
patient is diverted the tenderness on pressure may not be complained of. 
I am not familiar with the results in examination of the urine in this 
form of peritonitis. Indican should not be increased necessarily, as we 
find it in acute suppurative peritonitis. 

Rheumatism of the Abdominal Walls. There is absence of a history 
of sudden acute pain followed by general pain. The fever is not 
so great. The respirations are not interfered with, the pulse is not 
so rapid, and symptoms of collapse do not supervene. A rheumatic 
pharyngitis, or inflammation of muscles in some other portion of the body 
may occur simultaneously. Acute hemorrhagic pancreatitis may simulate 
peritonitis in the sudden intensity of pain and the occurrence of shock. 

Local Circumscribed Peritonitis. The causes of localized peritonitis 
are those of general peritonitis — that is, extension of inflammation 
from neighboring viscera, or perforation of the viscera. In the latter 

37 



578 



SPECIAL DIAGNOSIS. 



instance the inflammation does not become general, because of rapid 
local inflammation shutting off the perforated area from the general 
cavity of the peritoneum. Local peritonitis of mild degree and local or 
circumscribed peritonitis with suppuration, are therefore found in the 
neighborhood previously indicated, from which a general peritonitis 
may start. The inflammation, however, if retained by a limiting wall 
may, after suppuration has taken place, gradually extend and the pus 
burrow in various directions. In such cases of localized peritonitis 
as may exist in the upper half of the abdomen, a sub-diaphragmatic 
abscess may form, or an abscess containing air and pus, known as 
pyo-pneumothorax subphrenicus. If the inflammation is secondary to 
disease of the pancreas it may be limited to the lesser peritoneum and 
cause the physical signs of effusion in this cavity. (See Disease of the 
Pancreas). Sub-diaphragmatic abscess is not limited to the lesser peri- 
toneum. It can only be recognized by the history of previous disease on 
account of which perforation may take place, and by the general symptoms 
of abscess. If the abscess is on the left side there is extension of dul- 
ness upward toward the scapula, the lower limit of the lungs in health 
ceasing at the eighth or ninth interspace. There may also be dulness 
in the axillary region. If the abscess is on the right side it may simu- 
late enlargement of the liver and be characterized by marked increase 
in dulness anteriorly, laterally, or posteriorly. Localized peritonitis in 
the lower half of the abdomen is due to disease of the vermiform appendix, 
or to disease of the Fallopian tubes. The localized signs are, first, those 
of pain and tenderness; second, the development of tumor. 

Chronic Peritonitis. The symptoms of diffuse peritonitis, chronic in 
course, may follow the acute, or may occur in the course of tuberculosis. 
The intestines and peritoneum are matted together. General pain and 
tenderness, with a prolonged period of ill health, attend the diffuse form. 
(See Tuberculous Peritonitis.) In the chronic forms, particularly if 
there is considerable fibrous proliferation independent of cancer and 
tubercle, the abdomen becomes retracted, the muscles rigid, the note 
over the abdomen modified or dull tympanitic. The modification 
may be detected, in the upper half of the abdomen particularly, and 
especially over the liver. Sometimes a fremitus can be felt. The 
patients are under weight and without strength. The pain may continue 
a long time. It finally results, at least clinically, in such compensation 
that the patient is able to continue his usual occupation. Localized 
bands form, and may cause local sensations of a dragging character, 
or pain with drawing or pulling sensations, but, save the local symp- 
toms, these are not serious, unless it should happen, as has been seen in 
intestinal obstruction, that coils of intestine are twisted about the bands 
or caught in them, leading to obstruction. 

Ascites. 

Ascites is the accumulation of fluid in the peritoneal cavity. The 
causes may be local or general. It occurs, first, in simple, cancerous or 
tuberculous inflammation of the peritoneum ; second, in portal obstruc- 
tion from disease of the liver, as cirrhosis, or disease of the portal 



STOMACH, INTESTINES, AND PERITONEUM. 



579 



veins, either from compression or inflammation. Tumors of the abdo- 
men are often attended by ascites, particularly solid tumors of the 
ovary. The general causes of ascites are the causes of dropsy. 

Symptoms. The abdomen is enlarged, the enlargement being uniform. 
The skin is tense if the effusion is large, and linece albicantes may 
be seen. The navel may project. If the ascites is due to liver disease 
or disease of the portal vein the superficial veins may eularge, although 
the enlargement is sometimes seen when any effusion continues a long 
period of time. On palpation fluctuation can usually be detected. 
Care must be taken not to confound the wave of the abdominal walls, 
produced by percussion, with the wave of the fluid underneath ; the 
former must be cut off by the hand of an assistant placed vertically in 
the median line. The left hand should be applied firmly against one 
side of the abdomen, while with the right percussion or tapping is gently 
performed at the opposite point. The points selected should be at 
about the level of the fluid. At first the hand should be placed on the 
flank, and if the fluctuation is not revealed, then with each successive 
percussion it should be brought forward toward the median line. Some- 
times light percussion will yield the sign, at others more firm percussion 
must be employed. In order to ascertain the position of solid organs 
in ascites, dipping is employed by suddenly pressing the tips of the 
fingers over the organ sought for. The fluid is thus displaced and 
the edge or surface of the organ readily felt. The faintest tap may 
be sufficient. 

Percussion. When the abdomen is percussed in the usual manner there 
is dulness over the fluid. As the fluid gravitates to dependent portions 
the dulness is found in these portions. When the patient is lying down 
it is in the flanks, and may extend around the lower portion of 
the abdomen. If the patient stands up the dulness may reach to the 
umbilicus in the median line and to the same level in the mid-clavicular 
line. The subjective symptoms are those due to the cause of the ascites 
and to mechanical pressure. In ascites it is important to ascertain 
the nature of the fluid. This can only be done by aspiration. If 
the fluid is serous it has the characteristics belonging to that fluid. 
Hemorrhagic effusions usually occur in cancer and tuberculosis, 
although both of these diseases may occur with clear serum. In 
ruptured tubal pregnancy the effusion is hemorrhagic. In rare cases a 
chylous, milky fluid is found in disease of the lymphatics. In one 
instance this occurred from perforation of the thoracic duct. Chylous 
ascites may, however, be due to an excessive milk diet. In other in- 
stances it is due to filaria. The patient on a milk diet is often lipsemic, 
in consequence of which effusions are made turbid. 

Ascites must be distinguished from enlargement of the abdomen due to 
ovarian tumor, enlargement due to pregnancy, and enlargement due to 
an overdistended bladder. In ovarian tumor the development at first 
takes place to the right or left of the median line. If enlarged the 
signs of it may be in the central region of the abdomen. The flanks, 
however, are always tympanitic on percussion. On examination per 
vaginam the local disease may be ascertained. A distended bladder 
should always be thought of, and catheterization performed in cases of 



580 



SPECIAL DIAGNOSIS. 



doubt. Cysts of the pancreas may be mistaken for ascites, and large 
hydatid cysts connected with the liver may simulate an accumulation 
of fluid in the peritoneal cavity. The history and the appearance of the 
fluid on aspiration point to the diagnosis. 

Cancer of the Peritoneum. 

It usually occurs in the aged, and follows cancer in other organs, 
as the stomach, liver, or uterus. Occasionally it is primary. The 
omentum is indurated and forms a mass which lies transversely across 
the abdomen in the upper zone. Ascites usually develops, and the 
exudation is bloody. The disease occurs more frequently in women 
than in men. With the development of ascites there is emaciation. 
The surface of the indurated omentum is irregular. It may be painful 
on pressure. The same character of tumor is seen in tuberculous peri- 
tonitis, and I have seen several such tumors in the aged without apparent 
cause, unless from proliferative peritonitis. (See Tumor.) Progressive 
emaciation, chronic ascites without cause, and a localized tumor without 
the occurrence of fever, point to the probable nature of the case. Some- 
times pain is the most pronounced symptom. If these symptoms are 
present without symptoms of disease in other organs, as the stomach, 
rectum, or uterus, there is probably cancer of the peritoneum. 

Tuberculosis of the Peritoneum. 

The tuberculous process in the peritoneum may be either acute 
or chronic. In some instances it may continue without any symp- 
toms, either local or general. Acute tuberculous peritonitis may 
exactly simulate suppurative peritonitis, save that the course is more 
prolonged and the fluctuations of temperature less pronounced. In 
other respects it cannot be distinguished from acute general peri- 
tonitis, save in the absence of the causes of the latter. A history 
of liability to tuberculous infection, or the presence of tuberculosis 
in some other portion of the body, may be of service in determining the 
nature of the case. This is sometimes impossible. Usually there occurs 
in a short time associate tuberculosis of other serous membranes, so that 
tuberculous pleurisy or tuberculous pericarditis will supervene, an asso- 
ciate process which does not take place in ordinary peritonitis. At the 
same time in most cases there is a diarrhoea — at least this has been 
present in the few instances in which I have seen this form of tuber- 
culosis. 

Acute tuberculosis of the peritoneum may precisely simulate acute 
appendicitis in, first, the local symptoms and signs ; and second, the 
subsequent infection of the peritoneum. In acute tuberculous appen- 
dicitis, however, the signs of a tumor are nut so marked as in true 
appendicitis. Nevertheless, in one instance, Keen operated upon a 
patient of mine, a healthy laborer in a rolling-mill, who had the clas- 
sical symptoms of appendicitis. At the operation the appendix was 
found to be perforated and hanging in a local abscess. A feecal fistula 



STOMACH, INTESTINES, AND PERITONEUM. 



581 



ensued which did not heal, and within two months the patient died of 
general tuberculosis. The appendix was the seat of primary tubercu- 
lous ulceration. 

In the second instance the appendicitis arose in the course of tuber- 
culosis. 

In the third instance, the patient, aged forty-five, was admitted to 
my wards in the Philadelphia Hospital, with high fever and pain in the 
abdomen, at first more pronounced along the margin of the liver. It 
became more decided by the end of twenty-four hours in the right 
lower quadrant of the abdomen ; tenderness at McBurney's point was 
distinct, the area was enlarged, dull on percussion, the surface slightly 
oedematous. Fluctuation could not be detected. Extension of the 
leg was painful. Rapid general peritonitis ensued, during which the 
surgeon saw him, but declined to operate until the subsidence of the 
attack. When the attack subsided the local signs of tumor were not 
present. The fever persisted irregularly for a short time, indeed the 
more acute peritoneal symptoms subsided ; then the right pleura became 
infected, and cough ensued with expectoration of muco-purulent fluid. 
It did not contain bacilli, however. Subsequently, the left pleura and 
the pericardium became involved. During the entire course of the dis- 
ease there were diarrhoea, most pronounced sweats, rapid emaciation, and 
exhaustion. At the end of five weeks death took place, and at the 
autopsy general serous tuberculosis was found to be present. 

Fig. 88. 



M 


E ft 


E 




E 




E 


u 


£ 




E. 


M E 


M 


E 




E 




E M 


E M 


E 


M E 




E 




E 




E 


M E ft 


1 E M 


E 
















































































































































1 






































w 




































































t- 


A 


















r 


1 










-4 








( 








ft 














i 














* 












S 


























f 






























m 


I 








































ij 








T 






































































=\ 


















f 


















































r 












n 




















f 








f 



































































































Tuberculous peritonitis. Subnormal temperature. 



While in a number of instances the symptoms are acute and alarm- 
ing, in the larger proportion of cases the process is more chronic, and is 
attended by characteristic local and general symptoms. In the pro- 
longed and moderate cases there may be continued fever of moderate 
degree, or it may be remitting in type. In old people the fever is 
frequently subnormal (see Fig. 88). With the fever there is more or 
less rapid emaciation. The sweating is profuse and characteristic. In 
more severe cases the temperature is high but irregular in type, 



582 



SPECIAL DIAGNOSIS. 



approaching more the remittent form. The general symptoms very much 
resemble typhoid fever. Indeed, symptoms of the typhoid state may ensue. 

The Local Symptoms. Four classes are seen: (1) Abdominal en- 
largement with effusion ; (2) enlargement with tumors ; (3) combination 
of the two; (4) enlargement without marked evidence of fluid or tumor 
in the abdomen. In this form and in the forms in which tumors are 
present, the abdomen subsequently may undergo retraction. 

1. Enlargement tvith Effusion. The local symptoms and physical 
signs are those of ascites. The abdomen is never so distended, however, 
as in the ascites of cirrhosis of the liver. Often the fluid is not move- 
able on account of adhesions which may be distinctly localized in 
the right or left quadrant of the abdomen, in which situations fulness 
aud fluctuation may be readily detected. 

2. Tuberculosis with Tumors. The tumors are usually in the upper 
zone of the abdomen, and may be localized to either quadrant, or ex- 
tend from the right to the left. They are usually due to tubercu- 
losis of the omentum, with secondary contraction. In some instances 
a hard, indurated tumor, somewhat tender on pressure, may extend 
across the abdomen midway between the xiphoid cartilage and the 
umbilicus. It may be as low as the umbilicus, and vary from two to 
four inches in width. It may be continuous with the liver dulness. 
In other instances more distinctly localized masses may be felt. These 
may be to the right or to the left of the umbilicus. In other instances 
they are hard, slightly tender, with an irregular surface. They 
may be movable and alternate with the change of position of the 
patient. I have never seen tuberculous masses in the lower quadrants. 
In children with tabes mesenterica they may be made out close to the 
vertebral column in the median line, extending to the brim of the pelvis, 
although at the lower portion they are not so distinct. The dulness 
over the tumors is varying, dependent upon the relation to the bowels 
and the degree of their distention. Instead of dulness, a modified 
tympany may be observed, or muffled resonance. 

3. Cases in which Effusion and Tumors are Present at the Same Time. 
These present symptoms common to the two conditions, although the 
tumors are not so distinctly defined. 

4. Absence of Effusion and Tumors. When effusion and tumors 
are not present, the thickened peritoneum and more dense intestinal 
walls lead to a modified dulness over the entire abdomen. When 
retraction takes place the resonance is of a woodeny character, the 
abdomen is more or less tender, aud ill-defined indurations may be 
present. The term carreau is applied to these indurations. In not a few 
instances the local physical signs may apparently be due to inflamma- 
tion of the liver on account of extensive perihepatitis. In one case of 
a child, the local signs during life were qf this character, and the symp- 
toms were simply those of loss of appetite, with discomfort and weight 
aud fulness below the sternum. Both the right aud left lobes of the 
liver were covered with an enormous thickening due to tuberculous in- 
flammation. Simple plastic peritonitis occupied the lower zone. Apart 
from the general symptoms and the local physical signs the other 
symptoms are not distinct save those due to tuberculosis in other 



STOMACH, INTESTINES, AND PERITONEUM. 



583 



situations. The appetite is usually poor, there is some atonic dyspepsia, 
vomiting may occur at regular intervals; the bowels may be consti- 
pated, although in my experience they have usually been relaxed. The 
patient becomes anaemic, the skin harsh and dry. Emaciation may 
progress to an extreme degree Eruptions and boils may break out, 
some oedema of the ankles may occur. Death takes place from exhaus- 
tion, and from the development of tuberculosis in other localities. 

The diagnosis is difficult. The two extremes probably present the 
greatest difficulties. The age also modifies the ability to make a diagnosis. 
Peritoneal tumors with or without effusion in young subjects are almost 
always due to tuberculosis. In the aged they must be distinguished from 
carcinoma or chronic peritonitis from other causes. The association of 
diarrhoea with the symptoms is rather against carcinoma. Sacculated 
effusions may be confounded with abdominal tumors, as of the ovary. 
The resemblance is more pronounced if the tubercles develop primarily 
in the tubes or uterus. In a recent case the autopsy disclosed a large 
caseating ulcer inside of the uterus, and tuberculosis of the Fallopian 
tubes and peritoneum. The right tube was chiefly affected. The 
effusion during life was sacculated in the right quadrant, was not 
movable with the patient, and fluctuated both on external palpation 
and with bimanual palpation per vaginam. It was impossible to 
distinguish it except that there was dulness instead of resonance in 
the flanks. As Osier has poiuted out, the association with salpingitis 
must arouse suspicion, particularly if at the same time disease may be 
found in some other organ of the body, as the apex of the lung or the 
pleura. In males, the primary lesion is often in the testicles. The 
history of the case and the development of the disease in an irregular 
manner, associated with gastro-intestinal disturbance rather than dis- 
turbance of uterine function, are points in favor of tuberculosis. 
Tympanites is of frequent occurrence. 



CHAPTEE VI. 



DISEASES OF THE LIVER, SPLEEN, AND PANCREAS. 

The symptoms of disease of the liver are due to the morbid process 
which afiects the organ, to disturbance of the functions of the hepatic 
cells, or to obstruction of the channels for the flow of blood and bile. 
As the latter are beyond the glandular structure of the liver they may 
be affected by disease outside of the liver. Hepatic symptoms may > 
therefore, be due to disease outside of the liver. 

The morbid process may, in time, cause alteration in function, 
obstruction of channels, or physical alterations in the size and shape of 
the liver. The latter may also occur from disease outside of the liver. 

Symptoms due to the Morbid Process. The morbid processes, 
on account of which symptoms are created, are chiefly congestion of the 
liver, abscess, cancer of the liver, and the degenerations. 

In congestions of the liver the symptoms are (1) the symptoms of the 
cause, (2) enlargement of the organ on account of increased amount of 
blood, (3) functional disturbance for the same reason. The congestion 
is not limited to the vessels in relation to the liver cells, but involves 
the vessels of the mucous membranes also, hence the latter are swollen, 
by which the ducts are obstructed and jaundice is produced in moderate 
degree. In abscess of the liver we have the symptoms of suppuration 
and changes in the shape of the organ. Modifications of its function 
are not observed, and obstruction of the channels rarely takes place. 
In cancer of the liver the symptoms are those of malignant disease in 
general, to which are added symptoms due to change in the size of the 
liver, and, more frequently than in abscess, symptoms due to obstruction 
of the channels. The degenerations are so frequently secondary to and 
masked by the symptoms of their primary cause that, save in regard to 
change of size, there are no hepatic symptoms of note. 

Symptoms due to Functional Disturbance of the Liver. 
The functions of the liver are, first, to secrete bile ; second, to destroy 
the haemoglobin of the blood ; third, to destroy poisons entering the 
portal circulation through the intestinal tract, or modify their character. 
Bile is not secreted when the liver cells are destroyed, as in acute yellow 
atrophy ; giving rise to jaundice, hemorrhages, and grave cerebral symp- 
toms. In this case the liver does not destroy the normal amount 
of haemoglobin. On the other hand, haemoglobin may be so much in 
excess that the liver cannot destroy it ; hence jaundice is created (see 
Haematogenous Jaundice). Functional disturbances of the liver are seen 
clinically when products of digestion are not completely destroyed by 
the liver and are permitted to enter the circulation. In this manner 
we have, on the one hand, possibly, the occurrence of glycosuria ; and, 
on the other, the occurrence of lithaemia or other toxic states. 



LIVER, SPLEEN, AND PANCREAS. 



585 



Lithsemia is the more common condition believed to be due to liver 
disturbance. There is an excess of uric acid and urates or of other 
metabolic compounds in the blood. The symptoms that are produced 
are, first, symptoms of excess of lithic acid in the system ; second, the 
effects of the lithic acid upon the nervous system. Lithsemia may be 
acute or chronic. 

Acute Lith^mia ; Biliousness. When acute, the local disturb- 
ances are those of furred tongue, a bitter taste in the mouth, anorexia, 
nausea, disgust at the sight of food, with possible morning vomiting. 
There is some tenderness in the upper mid-abdomen, and after eating, 
weight and fulness and distress in that region. Flatulency occurs. The 
symptoms of intestinal dyspepsia may arise secondarily. Slight fever 
or feverishness may attend the attack. The skin is hot and burning ; 
or cold perspirations may break out at irregular times, alternating with 
flashes of heat. The bowels are constipated, the stools are clay-colored. 
The symptoms may be attended by slight obstruction to the ducts on 
account of which jaundice prevails in moderate degree. In some 
instances the liver can be made out slightly enlarged. The urine is 
loaded with urates and uric acid. It is scanty and high-colored, and 
there may be painful micturition. The nervous symptoms are usually 
those of depression, as headache, some dulness, or stupor ; the patient 
may be unusually drowsy. The headaches may be the most prominent 
feature of the attack. They are frontal, attended by slight vertigo, 
flashes of light or spots before the eyes, and ringing in the ears. 

The same group of symptoms is seen in acute gastro-duodenal 
catarrh. 

Chronic Lith^mia. In chronic lithcemia the symptoms are variable 
and are characterized by disturbance of function in nearly all of the 
organs of the body. They have been classically described by Murchi- 
son, Da Costa, and others, and while the theory is fairly satisfactory to 
work upon for lines of treatment, the same group of symptoms may be 
met with in forms of chronic indigestion, particularly the forms in 
which there is inability to digest sugars and starches. By some the 
symptoms are attributed to chronic intestinal catarrh. 

Symptoms. The patients are in ill health and subject to chronic in- 
digestion. They may be under weight or corpulent. The skin is harsh 
and dry, its nutrition poor. It is subject to erythema. The con- 
dition of the skin is such that local inflammations, as eczema, may 
arise. Irregular sweats occur, alternating with periods of hot, dry skin. 
The extremities are cold and clammy, and tingling and numbness are 
often complained of. 

G astro-intestinal Symptoms. The symptoms are those of chronic in- 
digestion There is constantly a furred tongue with local dyspeptic 
symptoms. The bowels are irregular or constipated; sometimes mucus 
is passed. Flatulency is prominent and marked, both gastric and 
intestinal. A slight icteric tinge may be seen on account of a slight 
local catarrh of the ducts or hepatic congestion. It recurs at frequent 
periods, while a sallow complexion is more or less constant. 

Respiratory Symptoms. The patient is liable to attacks of catarrh of 
the upper air-passages, and especially to pharyngitis. In lithsemic 



586 



SPECIAL DIAGNOSIS. 



states tonsillitis is not uncommon. Chronic pharyngitis is present. On 
the other hand, some persons, particularly those over fifty, have chronic 
bronchitis, and attacks of asthma are common. It cannot be distin- 
guished from bronchitis due to other causes, except by the fact that the 
subject is lithsemic. Emphysema of the lungs develops on account of 
bronchitis and tissue degeneration. 

Cardiac Symptoms. Palpitation of the heart is a constant accom- 
paniment of lithsemia in many states; in others there may be unduly 
rapid action of the heart, or, during exacerbations, slowness of the 
heart's action. In the later stages, pseudo angina pectoris is of com- 
mon occurrence. In the earlier stages pain about the heart or in the left 
side is frequently complained of. 

Nervous Symptoms. Constant headache, worse in the mornings, 
relieved in the after part of the day. Some vertigo may be present. 
There is depression of spirits and inaptitude for mental exertion. The 
memory is dull, the faculties blunted. The patient is subject to back- 
ache ; the pain is chiefly marked in the loins. Pain in the right 
shoulder is of frequent occurrence. In addition, pains along the course 
of the nerves (neuritis), and myalgias, are of common occurrence. The 
nerve-trunks may be tender. There is tenderness in the sheaths of the 
muscles, or at the insertions of fascia and tendons. Peripheral nerve- 
sensations are common. Numbness and tingling are frequently com- 
plained of. Paresthesia? of all forms, variously distributed, are a 
source of annoyance. Local sensations of heat or burning alternate 
with areas of coldness. Tingling, pricking of needles, and other forms 
of paresthesia occur. 

The Urine. In this class of cases the urine is high-colored and 
contains an abundance of uric acid and urates. The amount is scanty, 
the specific gravity high. There may be albumin, small in amount, de- 
pending upon the irritation of the urates in their passage through the 
kidneys. Cylindroids are present in the urine ; casts are not common, 
although at times when the uric acid is passed in excess there may 
be a secondary nephritis, with albumin, blood, and casts. As the ulti- 
mate results of such condition we find the development of gall-stones, 
or of calculi in the kidneys and bladder. Lithemic patients are subject 
to attacks of hepatic or renal colic. 

A further ultimate result is gout or rheumatism. Acute inflamma- 
tory rheumatism (rheumatic fever) does not belong to this category, but 
muscular rheumatism, subacute inflammation of the joints with moder- 
ate fever, true gout, and gout with its modifications when seated in the 
various joints, are the ultimate outcome of this process in the patient. 
Attacks of gout may occur in a patient who has not presented symptoms 
of lithetnia, but those who have symptoms of lithsemia are more sus- 
ceptible to causes which produce attacks of gout. The gouty and rheu- 
matic manifestations are due to the deposition of uric acid and urates 
in tissues which are not highly vitalized, and in which, therefore, the 
circulation is sluggish. 

Lithemic states later assume the gouty aspect. Tophi are seen in the 
situations natural to them. The appearance of the face is characteristic, 
with capillary congestions and stases. The patients usually become 



LIVER, SPLEEN, ANJ) PANCREAS. 



587 



more or less obese and are subject to attacks of glycosuria. Early in 
their life degenerations of vessels take place. The kidneys are always 
under an excessive strain. A considerable portion of material is not 
discharged that should be ; its effects upon peripheral vessels are such 
as to cause heightened tension, therefore undue vasomotor congestion 
of the vessels takes place, leading to low-grade inflammations, with the 
development of atheroma. For the same reason, chronic interstitial 
nephritis is set up, and because of heightened strain in the vascular 
system, chronic sclerotic valvulitis. 

Functional symptoms from disorder of the liver are otherwise not 
marked, unless we include a group of cases in which sudden coma and 
convulsions take place, presumably because material has been absorbed 
from the gastro-intestinal tract and enters the general circulation because 
of the abeyance of the function of the liver, the office of which is to 
destroy the material. Such symptoms may arise in organic disease of 
the liver, as cirrhosis. 

Symptoms due to Obstruction of the Channels. The 
symptoms are produced by disease of the channels or by disease outside 
of the channels, as in obstruction of the bile-ducts by pressure. (1) Ob- 
struction of the bile-ducts causes jaundice, at times pain, and at times fever. 
The three symptoms may occur singly or combined. Jaundice may occur 
alone in obstruction by gall-stones ; pain may occur with it, or jaundice, 
pain, and fever may occur together; rarely, pain or fever may be pres- 
ent alone. Each symptom will be described later. Obstruction of the 
blood channels causes hyperemias of the liver and portal congestions. 
The symptoms of each will be discussed ; suffice it to say that here 
again the symptoms are modified by the process. Thus, in portal 
obstruction from pressure, the symptoms are far different from the 
symptoms of portal obstruction due to suppurative inflammation of the 
vein. 

(2) Obstruction to the flow of blood takes place in hyperemia, which 
may be either active or passive, and in disease of the portal vein, rarely 
of the hepatic. 

Hyper cemia of the Liver. In the hyperwmias the liver is enlarged. 
If the hyperemia is active, painful distention may be complained 
of, and the organ may be the seat of some tenderness. There may be, 
in addition, weight and fulness in the liver region. Active hyperemia 
may follow a chill or suppression of the menses, but more frequently 
occurs after indiscretions of diet, the free use of alcohol, or stimulating 
food followed by an attack of acute gastro-intestinal catarrh. It is 
more common in the tropics, and is due in that climate to suppression 
of the perspiration. It is recognized by the occurrence of symptoms of 
acute gastritis with enlargement, pain and tenderness of the liver. 
Slight jaundice may attend the attack. Passive congestion is also 
attended by enlargement of the liver. The enlargement may cause a 
sense of weight or fulness, but pain is not complained of. The organ 
is not tender, the edges are smooth and indurated. The liver may 
pulsate. This is detected when the hand is placed over the surface of 
the liver, when, with each impulse of the heart, the organ can be felt to 
expand. The symptoms of the cause of the passive congestion combine 



588 



SPECIAL DIAGNOSIS. 



with those just narrated due to enlargement of the organ. To them 
must be added symptoms due to obstruction of the flow of blood in 
the portal circuit. Passive congestion occurs in orgauic heart disease 
after compensation has failed and the right heart is dilated. The organ 
rapidly becomes congested because of its close proximity to this chamber. 
In emphysema of the lungs, in fibroid phthisis, in intra-thoracic tumors 
pressing upon the vena cava, mechanical congestion takes place. The 
recognition of passive congestion is not difficult. The symptoms due 
to enlargement (see Objective Symptoms) and the symptoms due to portal 
obstruction point to the true nature of the hepatic lesion. 

The Symptoms of Portal Obstruction. These arise because of disease 
of the portal vein, or because of occlusion and obstruction to the flow 
of blood in the branches of the veins. The diseases of the portal vein are 
thrombosis, adhesive and suppurative inflammation. (1) Thrombosis of 
the portal vein attends cirrhosis of the liver, and may occur secondarily 
to pressure upon the vein by a tumor within the abdomen. Disease of 
the paucreas was the cause of the pressure in a patient under my observa- 
tion. As a result of the thrombosis, adhesive inflammation of the vein 
takes place, to replace which a collateral circulation is established. 

The symptoms of disease of the trunk of the portal vein which leads 
to obstruction of this character are the same as in obstruction of the ter- 
minal branches, and are known as the symptoms of portal congestion 
(see below). In one respect only do they differ. While in both we 
have ascites, in thrombosis of the portal vein it occurs suddenly, and 
is characterized by rapid recurrence after tapping. 

(2) Suppurative inflammation of the portal vein is attended by symp- 
toms resembling pyaemia; the condition is called portal pyaemia. The 
inflammation is secondary and depends upon inflammation in the portal 
area. It follows appendicitis with peritonitis, ulceration of the hemor- 
rhoidal veins, inflammation of the veins from ulceration or suppuration 
anywhere in the gastro-intestinal tract. The enlarged portal vein be- 
ing the seat of suppuration it naturally follows that pus is carried into 
the liver. In consequence thereof, multiple hepatic abscesses arise. 
Three pathological affections are therefore seen: (1) Suppuration in the 
portal area ; (2) during the height of the latter, or subsequently, symp- 
toms of pyaemia develop, chills and fever and sweats, followed by ex- 
haustion; (3) the occurrence of multiple abscesses of the liver (for the 
symptoms of which see Abscess). 

Symptoms of obstruction, due to congestion, overfilling, or obstruction 
of the branches in the liver. This condition occurs in passive conges- 
tion, but most typically in cirrhosis of the liver. The circulation of the 
liver being interferred with, the blood is thrown back into the portal 
vein and the other end of the portal circuit. As a result we have 
(1) congestion of the mucous membrane of the stomach and bowels, 
with the symptoms of gastro-intestinal catarrh; (2) dilatation of the 
veins, chiefly the hemorrhoidal, on account of which hemorrhoids 
develop ; (3) the occurrence of ascites ; (4) the occurrence of hemorrhages. 
Hemorrhages due to disease of the liver may occur in any portion of 
the gastro-intestinal tract. Haematemesis and intestinal hemorrhage 
occur. The vomiting of blood may be in small amounts, associated only 



LIVER, SPLEEN", AND PANCREAS. 



589 



with the discharge of mucus. In some cases large hemorrhages take place 
either from the mucous membraue of the stomach or from the veins about 
the oesophagus, which often become varicosed in cirrhosis. Hemorrhages 
from the intestine may occur from enlarged hemorrhoidal veins, from an 
intestinal ulcer which may be present, or from the mucous membrane 
of the intestinal tract. (5) Enlargement of the spleen. (6) The changes 
due to the establishment of the collateral circulation. If complete col- 
lateral circulation is established the above symptoms may not ensue. 
The collateral circulation may occur in deeply seated veins, or be estab- 
lished through the veins over the surface. If the latter, the external 
veins of the abdomen are enlarged. The epigastric and mammary veins 
become prominent. At times the veins about the umbilicus distend, 
and they may become so enlarged and prominent as to form a swelling 
to which the term caput Medusa; has been applied. The venules along 
the line of attachment of the diaphragm in the lower thoracic zone are 
overdistended. 

On account of the enlargement of the terminal branches of the 
portal vein in the liver they press upon contiguous structures and inter- 
fere with the circulation of blood in the major vascular system of the 
liver, and hence invite a catarrh of the terminal ducts, on account of 
which they are obstructed, and slight jaundice supervenes. This is 
seen quite frequently in passive congestion of the liver, rarely in 
cirrhosis. 

Symptoms due to Changes in Shape and Size. The liver 
may be enlarged, contracted, or irregular. (See Objective Symptoms.) 
Symptoms of portal obstruction occur when the liver is contracted. 

The Data Obtained by Inquiry. 

A number of extraneous factors are of aid in the diagnosis of hepatic 
affections. In disease of the liver more than in that of any other organ 
of the body we find the affection secondary to disease elsewhere. 
Moreover, diseases of the liver are almost always associated with pro- 
nounced and definite causes, the presence or absence of which are of 
great diagnostic significance. In the study of hepatic disease we con- 
sider, therefore, among etiological factors, the age of the patient, the sex, 
the habits of life, the climate, and the presence or absence of disease in 
other portions of the body. Primary liver disease is comparatively 
rare. Secondary liver disease, on the other hand, is of common occur- 
rence. But few general diseases or states of the system occur that do 
not in some way influence the liver. The above remarks refer to 
organic disease. Separation of functional disorders, as previously 
remarked, from functional disorders of the stomach and intestines, is so 
difficult that, practically, from an etiological and clinical standpoint, 
they go hand in hand. 

The Age. Diseases of the liver usually occur late in life because the 
causes upon which they depend are operative only at that period of life. 
In a case, therefore, of ill health in a young subject, the cause of which 
cannot well be determined, the liver is not so likely to be the seat of 
disease as in older subjects. Late in life we have the occurrence of 



590 



SPECIAL DIAGNOSIS. 



gall-stones with their multiple consequences, of cirrhosis, and of cancer. 
We may have in early life, although not so frequently, the congestions 
and the degenerations. 

The Sex. The sex is not of much significance from a diagnostic 
standpoint. Cancer may be more frequent in the female sex, because 
cancer of the uterus and other organs is more common. Cancer of the 
biliary passages is more frequent in females, because in that sex gall- 
stones, which are etiological factors in cancer, are more common. Cir- 
rhosis also is stated to be relatively more frequent in females. 

The Habits. It is always necessary to inquire into the habits in 
order to determine the diagnosis. Alcoholism points to cirrhosis ; the 
excessive use of stimulating foods to hyperemia ; sedentary habits and 
the use of starches and fats to gall-stones. The occupation has but 
little influence in the development of hepatic disease. With regard to 
climate it may be said that in tropical countries hyperemias and abscess 
of the liver are more frequent. 

Previous Disease. It is absolutely essential to inquire into this to 
establish a diagnosis. The occurrence of heart disease or obstructive 
lung disease points to a congestion ; infectious diseases to cirrhosis, 
when it cannot be accounted for otherwise ; dysentery to abscess ; ulcera- 
tion or suppuration in the portal area to multiple abscess ; syphilis to 
syphilitic disease ; tuberculosis, suppurations, bone disease, and syphilis 
to amyloid disease ; pyaemia to multiple abscesses ; tuberculosis to fatty 
liver. 

The Subjective Symptoms. 

The subjective symptoms are such as belong to functional disorder 
of the liver, conspicuous among which are gastro-intestinal symptoms- 
and toxaemia. (See Functional Disturbance and Lithsemia.) 

Pain is a frequent symptom of liver disease. "When sudden in onset,, 
acute, and increased by pressure or movement, it is due to perihepatitis. 
Acute paroxysmal pain below the ribs points to gall-stones. It may 
be in the seventh or eighth interspaces. The paroxysms may occur at 
varying intervals and are often attended by jaundice. Pain with dis- 
tention occurs in congestion. Stabbing or darting pains occur in 
cancer. The pain of perihepatitis may attend abscess. 

Pain in the liver must not be confounded with pleurisy. In pneu- 
monia there is often congestion of the liver and perhaps perihepatitis. 
The pain has been taken for the pain of hepatic colic. 

The Data Obtained by Observation. The Objective Symptoms. 

Topographical Anatomy. The right lobe of the liver is applied 
to the concavity formed by the lower lobe of the right lung, being 
separated from it by the diaphragm. The thin lower edge of the right 
lung overlaps the liver at its upper part, but the greater portion of the 
anterior surface of the right lobe of the liver is iu contact with the ribs. 
The under surface of the liver is in relation with the stomach, trans- 
verse colon, duodenum, right kidney, and right supra-renal capsule. 
" The highest part of its convexity on the right side is about one inch 



LIVER, SPLEEN, AND PANCREAS. 



591 



below the nipple, or nearly on a level with the external and inferior 
angle of the pectoralis major. Posteriorly the liver comes to the surface 
below the base of the right lung, about the level of the tenth dorsal 
spine/' (Holden.) 

Roughly speaking, the upper border of the liver corresponds with 
the level of the tendinous centre of the diaphragm, that is, the level of 
the lower end of the sternum. Thus a needle thrust into the right side, 
between the sixth and seventh ribs, would traverse the lung, and then 
go through the diaphragm into the liver. 

The attachments of the liver permit of a certain amount of movement. 
Hence the liver can be depressed by deep inspiration, emphysema of the 
lungs, or right pleural effusion. If the patient lie upon his left side 
the left lobe of the liver rises higher aud the right extends lower, and 
vice versa if the patient lie upon the right side ; the liver turning upon 
the suspensory ligament as an axis. (Gerhardt.) 

Inspection. Inspection is not of very great assistance in the diag- 
nosis of diseases of the liver. Frequently there is a swelling in the 
right upper quadrant, which may or may not be produced by an enlarge- 
ment of the liver, but which should direct attention to that organ. 
The lower right zone of the thorax may also be distinctly prominent. 
Such a swelling may be observed in amyloid disease, hydatid tumor, 
cancer, abscess, and less frequently in fatty liver. In amyloid and fatty 
livers the projection in the right upper quadrant, which may extend to 
the left beyond the median line, preseuts a smooth surface, whereas in 
hydatid tumor there is frequently a rounded projection at some part of 
the prominent area, and in cancer several nodules may be large enough 
to cause slight rounded projections, which the eye is more apt to detect 
after the sense of touch has first directed attention to their presence. 

Enlargement of the superficial abdominal veins on the right side is a 
common accompaniment of cirrhosis. 

Jaundice. The color of the skin and of the mucous membranes 
which takes place in jaundice has been described (see page 7 J). In 
addition to the yellow discoloration jaundice causes a number of 
symptoms: 1. Irritations of the skin. Pruritus is common and intense, 
and may cause great distress. An attack of jaundice may be preceded 
by general itching. It occurs in all forms, but is more marked in 
obstructive jaundice of long duration. Scratch-marks are seen on the 
surface of the skin, and erythematous eruptions and boils frequently 
occur. Xanthelasma is a peculiar affection occurring on the tongue, on 
the skin of the eyelids, and about the ears (see page 123). 2. Discolora- 
tion of the secretions. All the secretions of the body are changed in 
color, as previously described. 3. Bile absent in the forces. The stools 
are ashy, or gray in color. 4. Slowness of the pulse. The heart's 
action falls to 40 or 30 to the minute, or even lower. 5. Hemor- 
rhages. In the later stages of all forms of jaundice hemorrhages are 
of common occurrence. In acute malignant jaundice they are seen 
underneath the skin, and occur from the mucous membranes. 6. Cere- 
bral symptoms, irritability, and depression of spirits are marked. As 
the disease advances mental acts become sluggish ; the patient is dull, 
and sleeping most of the time. Gradually the symptoms of the 



592 



SPECIAL DIAGNOSIS. 



typhoid state develop. In the acute febrile forms, coma and convul- 
sions follow this condition. In the affection known as acute yellow 
atrophy the cerebral symptoms are marked, and occur early. Within 
the first twenty-four hours there may be convulsions, with delirium 
in the intervals, aud subsequently coma. 

Causes. Jaundice is (a) hematogenous or non-obstructive when (1) 
the function of the liver cells has been suppressed, as in acute yellow 
atrophy of the liver ; (2) when blood destruction is in excess of the 
capacity of the liver to remove the products of destruction, the bili- 
rubin, as in certain forms of malaria, in pernicious anaemia, in certain 
fevers, and other toxaemias ; (6) hepatogenous when there is obstruc- 
tion of the ducts. The obstruction may take place in the large ducts 
or in the smaller terminal ducts. The obstruction is due (1) in the 
large ducts, to disease outside of the ducts; (2) in large and smaller 
ducts, to disease of the ducts; or (3) in all sizes, to obstruction within 
the ducts. Hence we have jaundice. 

1. From the pressure upon the ducts, of tumors connected with the 
stomach, kidney, pancreas, or the omentum ; of tumors of the liver 
itself, or enlarged glands in the fissure of the liver ; of accumulated 
faeces in the colon ; of abdominal aneurism ; and in rare instances, of 
the pregnant uterus. 

2. From catarrhal inflammation of the mucous membrane of the 
ducts ; suppurative inflammation of the same ; adhesive inflammation 
of the ducts ; cancer or other tumors at the orifice, or within the duct. 

3. From foreign bodies within the ducts, as inspissated mucus, gall- 
stones, or parasites. 

Diagnosis. Jaundice due to disease outside of the ducts is gradual in 
onset, varies in degree with the extent of pressure, becomes chronic, 
except in pregnancy and from faecal accumulation ; may cause a fatal 
termination, or persist until such termination results from the primary 
disease. It may be recognized by the absence of pain ; the presence of 
disease in other localities, indicated by the symptoms and signs thereof ; 
the absence of a history of gall-stones ; and finally, the age of the 
patient. In the large majority of cases this form of jaundice is due to 
disease of the pancreas, particularly carcinoma. 

Jaundice due to disease of the ducts presents varying features. The 
most common form is that due to catarrhal inflammation of the ducts. 
The jaundice comes on suddenly, at least within forty-eight hours after 
the onset of the symptoms ; it occurs without pain, and is attended by 
vomiting and other symptoms of mild gastritis. The jaundice is 
usually attended by itching. It follows indiscretions in diet, and 
occurs in young subjects. Generally a pronounced cause for the gas- 
tritis can be ascertained. If the jaundice is due to suppurative inflamma- 
tion of the ducts there is a history of gall-stones preceding, on accouut 
of which the suppuration took place. It must not be forgotten, how- 
ever, that other lesions which cause jaundice may cause suppurative 
inflammation of the ducts also, such as obstruction by external pressure. 
The course of the jauudice is chronic. Fever and other symptoms of 
suppuration attend it. In adhesive inflammation there is a history of 
trauma from gall-stones, and the affection is chronic. In cancer of the 



LIVER, SPLEEN, AND PANCREAS. 



593 



gall-ducts the advent of the jaundice is slow, the course protracted; the 
symptoms are the symptoms of carcinoma, to which are often added the 
symptoms of suppuration. (See Disease of the Gall-ducts.) 

Foreign bodies within the duds cause jaundice by direct obstruction, 
or because of the catarrhal inflammation which their presence excites. 
The symptoms occur suddenly in the former instance, gradually in 
the latter. The characteristic symptoms of gall-stones precede the 
jaundice. The patient is usually a woman past forty with habits of 
life which predispose to the formation of calculi. 

Jaundice due to lowering of the blood pressure in the liver, so that 
the tension is altered between the bile-ducts and the blood passages, 
occurs suddenly, is light in degree, and is not attended by marked symp- 
toms of jaundice ; it is due usually to shock or depressing emotions. 

Hematogenous jaundice must be distinguished from hepatogenous 
jaundice. In the hematogenous form the onset of the jaundice is 
more rapid, the general symptoms that attend it are more pronounced, 
particularly the nervous symptoms. With the onset of discoloration 
cerebral symptoms are observed. This is particularly the case in acute 
yellow atrophy of the liver. In the toxic forms of hematogenous jaun- 
dice in which there is no obstruction the symptom is not severe ; the dis- 
coloration of the skin is light yellow ; it may not be observed by the 
patient, and does not cause pronounced symptoms. The blood is destroyed 
rapidly in these cases, and as it cannot be disposed of by the liver, spleen, 
or kidneys, the transformed haemoglobin is deposited in the tissues. In 
this class of cases the urine contains but little bile pigment, but there is a 
large amount of bilirubin and indican. The stools are not clay-colored. 

Infantile Jaundice. Jaundice in infants is due to two causes : 
First, congenital obliteration of the ducts ; and, second, catarrhal 
inflammation. It must not be confounded with the yellow discolora- 
tion of the skin due to the excess of coloring matter of the blood 
which is not disposed of by the liver. In congenital obliteration of the 
gall-ducts jaundice rapidly ensues, and deepens to an intense degree ; 
hemorrhages occur, the child becomes stupid or comatose, may have 
convulsions, and death takes place in coma. There is rapid emaciation, 
and the liver and spleen are enlarged. The child may live many months. 

Simple catarrhal jaundice in infants is associated with moderate gas- 
tric disorder. The jaundice is light; the conjunctiva alone may be dis- 
colored. In infants malignant jaundice may be due to inflammation 
of the portal veins secondary to umbilical phlebitis. The jaundice 
develops after local inflammation about the umbilicus, in which a 
slight puriform discharge is seen at the navel, attended by an increase 
in temperature. There may be some tenderness over the liver; fre- 
quently peritonitis develops at the same time. Pyemic symptoms may 
set in, and pus be found in other situations. If the fever and pyemic 
condition do not cause death the jaundice becomes more pronounced, 
and causes cutaneous and mucous hemorrhages. Convulsions and coma 
are apt to supervene before death. Jaundice in infants also occurs in 
interstitial hepatitis of syphilitic origin. The evidences of hereditary 
syphilis are seen in the skin and mucous membranes. The liver is 
enlarged, and there may be tenderness on account of perihepatitis. 

38 



594 



SPECIAL DIAGNOSIS. 



Malignant Jaundice. Acute Yellow Atrophy of the Liver. 
Acute diffuse inflammation of the liver with necrosis of the cells, 
characterized by jaundice aud cholsernia. It occurs very frequently in 
females during pregnancy. It is most common prior to the thirtieth 
year of age. It is said to follow fright. The symptoms are local and 
general. Jaundice at first is noticed coming on after an attack of gas- 
tro-duodenal catarrh. It is light, occasionally extends over the entire 
body, is not usually attended by itching. Within twenty-four or forty- 
eight hours the patient complains of headache ; delirium sets in with 
stupor and the occurrence of convulsions. With the onset of the head- 
ache vomiting takes place. Fever of moderate degree begins at the 
same time, although in some cases it is absent. Although the jaundice 
is not intense, the effects upon the blood are early seen. Hemor- 
rhages underneath the skin and from the mucous membrane take 
place. In pregnant women abortion follows, the hemorrhage from 
which may be very excessive. The stupor and delirium are followed by 
coma, and death takes place within a week of the onset of the disease ; 
or coma may be preceded by the typhoid state, and the disease last for 
a week or more. The urine is bile-stained, and contains albumin and 
casts. It diminishes in amount, and is soon passed involuntarily. 
Leucin and tyrosin are always present. The latter may be seen in the 
sediment, although it is more marked when a few drops are evaporated 
on a cover-glass. The bowels are loose and the stools involuntary and 
clay-colored. 

On examination of the liver the organ is found to be diminished in 
size ; this may not be appreciated by percussion in the anterior region, 
but in the axillary region the width is reduced one or two inches. 
There may be some tenderness over the liver and over the ducts. The 
data upon which a diagnosis is based are the age, sex, occurrence of 
pregnancy, the rapidity of onset of cerebral symptoms following jaun- 
dice, diminution in the size of the liver, with leucin and tyrosin in the 
urine. It must be distinguished from the jaundice that attends hyper- 
trophic cirrhosis of the liver, which at times becomes malignant. Some 
observers have thought that necrosis of cells had supervened upon this 
lesion, but fever is more marked in this form of jaundice, and leucin 
and tyrosin are absent from the urine. 

It must not be forgotten that all cases of jaundice may terminate 
suddenly with delirium, followed by coma, or by the development of 
the typhoid state. In phosphorus poisoning the hemorrhages, the 
jaundice, and diminution in the size of the liver are the same as in 
acute yellow atrophy. Gastric symptoms are more marked, and leucin 
and tyrosin are not present in the urine. 

Fever. Hepatic Fever. In addition to the determination of the 
cause of jaundice by the character of symptoms and the associate 
phenomena, the occurrence of fever may be of diagnostic importauce iu 
distinguishing the various forms of obstructive jaundice. Fever occurs 
frequently in jaundice, but usually attends only certain forms. In 
catarrhal jaundice it is present for three or four days only, disappearing 
as the severe gastric symptoms subside. In hepatic colic it is transitory 
and associated with chills and sweats. In jaundice from obstruction 



LIVER, SPLEEN, AND PANCREAS. 



595 



it occurs, first, when the obstruction is due to gall-stones without 
secondary changes in the liver ; second, in suppurative inflammation 
of the ducts produced by the stone or from other causes. Fever under 
these circumstances assumes a peculiar form which, on account of its 
association with disease of the liver, is known as intermittent hepatic 
fever (see p. 114). The fever is associated with obstructive jaundice 
in the following groups : First, with each paroxysm of hepatic colic 
both fever and jaundice are present. The latter, becoming more intense 
after each paroxysm, may persist for months or years. Second, jaundice 
persists, and is attended by distinct ague-like paroxysms of chill, fever, 
and sweat, after each of which the jaundice is more intense. Third, 
pain in the liver and gastric disturbance, with fever, but without 
jaundice. The pain aud gastric disturbance occur in distinct par- 
oxysms. Gall-stones are probably the cause in all these conditions, 
leading in some to chronic obstruction of the duct without suppuration. 
If suppuration is present the symptoms are somewhat different. Thus, 
(1) there is more tenderness in the hepatic region, with enlargement 
of the gall-bladder ; (2) paroxysms are more frequent in suppura- 
tive inflammation ; (3) jaundice is not so intense aud not influenced by 
paroxysms; (4) in suppurative inflammation the patient is ill in the 
intervals, aud there is wasting. There are are no periods of improve- 
ment locally or in the general condition. The most important point is 
the comparative ease in the intervals between the paroxysms of fever in 
the case of gall-stones. 

Intermitting fever of this character must be distinguished from 
malaria. The history of gall-stones, with pain in the region of the 
liver, aud the negative appearance of the blood, are sufficient to point to 
the diagnosis. 

Fever in disease of the liver also occurs in cancer when the neoplasms 
grow rapidly, in certain forms of cirrhosis, and in obstruction from 
other causes than gall-stones. It is particularly common in suppurative 
inflammation of hydatid cysts, or after they rupture and discharge into 
the biliary vessels. Without previous knowledge of the hydatid cyst the 
diagnosis is almost impossible, save that the pain is less when obstruc- 
tion is due to this cause than in obstruction from the passage of gall- 
stones. 

Weil's Disease. Acute febrile jaundice, which rapidly becomes 
malignant, occurring in butchers, laborers, and brewers, has been 
described by Weil. After exposure to cold generally, as in a beer 
vault, the patient is seized with a chill, followed by fever, w T ith head- 
ache, vomiting, and epigastric pain. Jaundice sets in rapidly. The 
temperature remains high and may be intermitting. Stupor, delirium, 
and coma, albuminuria with suppression of urine, subcutaneous hemor- 
rhages, and hemorrhages from mucous membranes rapidly ensue. Black 
vomit occurs early. In one of my cases there was enlargement of the 
liver with oedema over the surface. The microscopical appearances 
were those of acute diffused parenchymatous inflammation. In another, 
a breweryman, the liver was enlarged, but without unusual change, save 
congestion. 

The delirium is sometimes violent. The appearance and symptoms 



596 



SPECIAL DIAGNOSIS. 



suggest acute yellow atrophy of the liver. The setiological distinctions 
are noteworthy : the liver is not small ; leucin and tyrosin are not found 
in the urine ; the jaundice is more intense. The diagnostic circum- 
stances of epidemic and contagious diseases serve to exclude yellow fever. 
(See Yellow Fever.) 

Palpation. By palpation the lower border of the liver can be deter- 
mined in thin subjects or in those in whom the liver is greatly enlarged. 
It may be difficult to determine the border when the abdomen is dis- 
tended on account of flatulency. Careful palpation must be made with 
the tips of the fingers, firmly pressing them inward along the margin 
of the ribs, at the same time securing relaxation of the abdominal 
muscles by having the patient take a full breath, and having the legs 
drawn up and the shoulders elevated. The pressure should be made in 
the intervals following the act of inspiration. By care and patience 
the fingers can be pushed deeply inward and be made to feel the border 
of the liver, even in health. Care must be taken not to cause contrac- 
tion of the right rectus muscle, for if this takes place the indurated mass 
may simulate tumor or enlargement of the liver. The left lobe of the 
liver below the ensiform cartilage extends half-way to the umbilicus. 
Here it is most accessible to palpation. By palpation we also determine 
the size of the gall-bladder and the degree of movement of the liver in 
respiration. On full inspiration the liver descends, and during the act 
of expiration rises again. This movability is of service in determin- 
ing the liver from other organs that are fixed within the abdomen. 

In amyloid disease the lower edge is smooth, rounded, the tissue 
dense and unyielding to pressure, and the anterior surface perfectly 
smooth, as a "rule; but when the liver is also cirrhotic or syphilitic, the 
surface may be irregular and fissured. 

The fatty liver has also a rounded smooth border, but its tissue is not 
so dense and resistant, except when cirrhosis coexists. Its surface is 
smooth. 

In single abscess the liver is enlarged, but not uniformly, and not 
invariably. If the abscess is located in the right lobe and nearer the 
anterior than the posterior surface, palpation may be able to detect not 
only enlargement but also deep-seated obscure fluctuation, surrounded 
by a zone of hard tissue. The tumor is round, smooth, tense, tender 
and painful. 

In multiple abscesses the liver is enlarged uniformly, and usually 
none of the abscesses are large enough to be felt as a distinct promi- 
nence. The liver is tender and painful. 

In hydatid tumor the degree of enlargement depends very much 
upon the situation of the cyst, upon its stage of development, and upon 
the activity of the echinococci. Sometimes the cyst is so small that its 
existence remains unsuspected ; at other times the enlargement is so 
great as to fill the abdominal cavity. As in abscess, the possibility of 
detecting the tense, globular, fluctuating, painless tumor characteristic 
of the disease, depends upon its situation. If upon the anterior sur- 
face or lower border, this is very easy, especially if the tumor is at all 
large ; but if it projects from the posterior surface or from the upper or 
lateral borders detection of the tumor is difficult, and may be impossible. 



LIVER, SPLEEN, AND PANCREAS. 



597 



Iu congestion of the liver the enlargement is not so great as in abscess r 
nor are pain and tenderness so pronounced. Moreover, the enlarge- 
ment is usually not permanent. The lower border, as it projects below 
the edge of the ribs, is smooth. 

In hypertrophic cirrhosis the enlargement is moderate, the surface 
smooth or but slightly roughened, denser than normal, and somewhat 
tender. 

In cancer the enlargement resembles that of single abscess and 
hydatid tumor in that it is irregular. But, unlike hydatid tumor, the 
irregularities are due to knobs which project from the surface of the 
liver, are usually entirely free from any fluctuation, and are tender on 
palpation. There may be a single large mass, or a number of knobs or 
nodules. The part projecting below the ribs may be free from any 
nodules. 

Palpation of the liver may discover a friction from perihepatitis, and 
pain or tenderness from that cause, cancer or abscess. Pulsation of the 
liver may be a transmitted impulse from the abdominal aorta or a 
venous pulse, such as occurs also in the jugulars, from tricuspid regur- 
gitation. 

Floating liver is diagnosed by feeling in the lower, most frequently 
the right portion of the belly, a large tumor which can easily be con- 
founded with tumors of other organs. It can be distinguished as liver : 
(1) By recognizing the notch ; (2) by the presence of a tympanitic note 
in the proper region of the liver, as loops of intestine lie between the 
diaphragm and liver ; (3) by excessive movability of the tumor ; and 
(4) by ability to replace the liver in its proper position. It occurs 
almost invariably in women, probably as the result of a congenital 
lengthening of the suspensory ligament. 

Constriction of the Liver from Tight Lacing (Schnurleber) occurs 
especially in women. Tight corsets and still more tight waist-straps or 
bands squeeze the liver downward, especially the right lobe, so that it 
can be palpated. In more pronounced degrees of the condition a fur- 
row, often palpable, is produced, and below this a constricted lobe 
which may extend as far down as the anterior superior spine of the 
ilium and carry the gall-bladder with it. 

Lobes so depressed are usually thin and easily movable, and can be 
grasped with the hand and moved to and fro. If the lobe does not reach 
so far downward it is more rounded and blunt in shape. It is not 
always easy to demonstrate its connection with the liver, because coils 
of intestine lie over the liver in the furrow, make palpation difficult, 
and introduce a tympanitic note between the liver dulness and the dul- 
ness of the constricted lobe. 

Confusion with tumors of other kinds cau be avoided usually by 
deep palpation or percussion. 

Gall-bladder. When the gall-bladder has a certain degree of 
fulness, it may, according to Gerhardt, be not only felt in healthy per- 
sons, if the stomach and bowels are empty, as a smooth, round, fluc- 
tuating tumor at the lower border of the liver, but be even visible and 
be outlined by percussion. If a line is drawn from the right acromion 
process to the umbilicus, it will bisect the gall-bladder at a point where 



598 



SPECIAL DIAGNOSIS. 



it passes over the margin of the ribs. The fundus is situated below 
the edge of the liver, at about the ninth costal cartilage, just outside the 
edge of the right rectus muscle. Palpation is easy when, owing to closure 
of the cystic duct, the gall-bladder is disteuded with bile or with 
inflammatory exudate, or enlarged by thickening of its walls or by an 
accumulation of gall-stones. A pear-shaped tumor is then felt which, 
if not adherent to the border of the liver, is shoved up and down with 
it. In simple stasis, hydrops vesica? fellese, and purulent inflammation, 
the tumor is tense and elastic; in inflammatory or carcinomatous 
thickening of the wall, dense and irregular. Calculi can often be 
recognized by their form or hardness or by the sound made by rubbing 
them together. 

Aspiration. We are warranted in determining the nature of an 
obscure enlargement of the liver or of the gall-bladder by aspiration. 
In abscess, pus ; iu hydatid disease, the characteristic fluid, may be 
withdrawn. 

In a case of local enlargement the apex of the swelling should be 
aspirated. If aspiration is performed near the upper border the needle 
should be thrust downward ; if near the lower border, upward. The 
left lobe should be aspirated with care in order that the stomach be not 
pierced . 

Percussion. Alterations in Size and Shape of the Liver. The liver 
may diminish in size or it may enlarge. Diminutionin size can only be 
recognized by percussion. The normal extent of hepatic dulness is 
diminished. This is usually more marked in the anterior and lateral 
regions. It must not be confounded with the apparent diminution that 
takes place in emphysema, or that may occur from distention of the 
bowels with flatus, as in peritonitis. Absence of hepatic dulness may 
occur when there is gas in the peritoneal cavity. Enlargement of the 
liver is determined by inspection, palpation, and percussion. 

By percussion the size of the liver is accurately made out. Any 
marked increase beyond the normal limits (see p. 590) usually means 
increase in size of the liver. Both superficial and deep percussion must 
be performed. The upper border is determined by percussing from a 
point beyond the liver area toward the liver — anteriorly from the third 
interspace downward, laterally from the fourth, and posteriorly from 
the angle of the scapula. In health the upper border of the liver is 
found at the fifth interspace ; iu the axilla, at the sixth ; and in the back 
at the ninth interspace. From thence downward hepatic dulness should 
continue to the margin of the ribs. It falls short of this position by 
at least an inch in the aged, and in persons with a deep chest it may in 
front not be more than two inches in width. The width of the liver 
dulness in the right mid-clavicular line is about four inches, in the 
mid-axillary line six, in the mid-scapular line three inches. 

The enlargement may be uniform, it may be limited to one lobe, or it 
may be irregular. By percussion it may be found that the enlargement 
is regular from increase in size upward or downward, or increase in the 
area of dulness in both directions. On the other hand, the enlargement 
may be irregular. The liver dulness may begin higher iu the anterior 
region than in the axillary region, or may extend downward over the 



LIVER, SPLEEN, AND PANCREAS. 



599 



margin of the ribs in a circumscribed area. Sometimes the enlargement 
is limited to the left lobe and the increase in size noted by increase in the 
dulness from the xiphoid cartilage downward as far as the umbilicus. 
The entire middle region to the navel may be filled up by the enlarged 
liver. 

Uniform enlargement of the liver is due to congestion, fatty degenera- 
tion, amyloid disease, cancer of the liver, and sometimes to hydatid 
disease and abscess of the liver. Enlargement of one lobe of the liver 
is due to hydatid disease, to abscess, or to cancer, in nearly all cases. 
Either the right or the left lobe may be the seat of such enlargement. 

Enlargement in one particular direction is due also to the three con- 
ditions just indicated. Although enlargement downward by abscess or 
hydatid disease is the more common one, the enlargement may be directly 
upward, the lower border of the liver occupying the normal position. 
Enlargement of the liver upward is due to a cyst, or an abscess, which 
has developed in the convex surface of the right lobe. 

Irregularity in the shape of the liver dulness occurs in cancer, in 
abscess, and hydatid disease. Notwithstanding the apparent irregularity, 
enlargements of the liver always occupy the normal site of the organ 
and conform to its usual outline, with but moderate variations only. 

Enlargements of the liver must be distinguished from enlargement of 
organs in contiguity with the liver, or from structures usually containing 
air, which have become solid or non-resonant structures. The enlarge- 
ment must therefore be distinguished from pleural effusion, or disease of 
the lungs which causes dulness on percussion, or from disease of the 
abdominal organs on account of which there is increased dulness near 
the hepatic region. Hence, in renal tumors, in tumors associated with 
the large intestines or stomach, in ovarian tumors, in tumors due to 
accumulation of faeces, the physical signs on percussion may show their 
similarity to enlargement of the liver. 

Simulated Enlargement. It is well to bear in mind the conditions which 
simulate enlargement of the liver. Of these we have : (1) Congenital mal- 
formation ; the liver may be of abnormal shape, on account of which the 
area of dulness will be increased in a particular direction. It may be 
quadrangular or rounded. The liver may be found in the right pleural 
sac in congenital diaphragmatic hernia. The increase of dulness upward 
will simulate enlargement of the liver. Congenital malformations may 
be suspected in the absence of any symptoms of hepatic disease, or of 
conditions which may cause other forms of spurious enlargement. More- 
over, the increased dulness will have existed from early life. (2) In 
rhachitis on account of the malformation of the chest, the position of 
the liver may be such that its area will increase every way. For 
the same reason the liver may be felt below the margin of the ribs. 
(3) Disease of the spinal column causes dislocation, on account of which 
the liver may appear to be apparently increased in size. (4) Enlargement 
of the liver must be distinguished from pleural effusions. This is some- 
times difficult. The symptoms of the pulmonary affection must be con- 
sidered. The general conditions which cause hydrothorax must be borne 
in mind. The difficulty in distinguishing the tw T o occurs because the 
dulness of each is continuous. In the pleural effusion, however, there 



600 



SPECIAL DIAGNOSIS. 



is uniform bulging of the affected side. The liver is not movable, 
the chest expansion is lessened. The upper border of dulness of the 
fluid may be movable if the effusion is not large. If the effusion is 
small the line of dulness is S-shaped. It is high behind and high in 
front. If the effusion is large the upper limit of dulness is horizontal. 
The upper limit of dulness in the pleural effusion changes its position 
in many instances. In enlargement of the liver the lower costal ribs 
are often everted, but in pleural effusion a depression may be seen between 
the lower margin of the ribs and the upper surface of the liver, if the 
latter is dislocated by pressure of the fluid. Sometimes enlargements of 
the liver give rise to secondary pleural effusion, so that too often after 
finding pleural effusion the size of the liver is not estimated. (5) Peri- 
cardial effusion and dilated heart are said to simulate enlargement of the 
liver. The history of the case, the origin and mode of development of 
the symptoms, the physical signs of cardiac disease, point to its true 
nature. (6) Enlargement of the liver may be due apparently to sub- 
diaphragmatic abscess. The accumulation between the liver and dia- 
phragm causes the latter to be pushed downward. It is very difficult 
to distinguish the spurious from the false in these instances. Aspiration 
may help in the diagnosis. (7) Abnormal Conditions of the Abdominal 
Parietes. Increased tension or spasm of the recti muscles. Phantom 
tumors of the abdomen simulate enlargement of the liver. They occur 
in young girls, associated with gastro-intestinal catarrh and symptoms 
of hysteria. Anaesthesia must often be employed to disperse the 
phantom. 

(8) Tight Lacing. This may displace the liver upward or downward, 
according to the direction of pressure. It may also, by exerting lateral 
compression, bring more of the liver into contact with the anterior 
abdominal wall. And finally, if the constriction has been by a strap 
or tight cord, a portion of the liver may be more or less detached and 
appear as a movable tumor. 

(9) Some enlargements of the abdominal contents cause spurious 
enlargement of the liver. In the same way increased abdominal pressure 
(ascites, tympanites, etc.) causes the liver to rise higher than normal. 

a. The accumulation of faeces in the colon. This causes continuance 
of liver dulness downward, on account of which it may be thought that 
the patient has liver disease. A purgative must be given. 

b. An ovarian cyst. 

c. The presence of ascites. Exclusion of the latter is sometimes difficult 
because the ascites may be loculated and situated in the hepatic region. 
It may give rise to symptoms of hepatic enlargement. Probably aspiration 
alone can make the diagnosis distinct. Ascites should be easily distin- 
guished by the physical signs and the results of exploratory puncture. 

d. Tumors of the omentum, chiefly tuberculous, may occupy such rela- 
tion to the liver as to increase the dulness downward. The history, 
the occurrence of the omental tumor, with symptoms of tuberculosis, 
may aid in determining the true condition. 

e. In tumors of the kidney which simulate enlarged liver it is found 
that the edge of the liver cannot well be felt, but Murchison thinks the 
fingers can usually be inserted between the ribs and the upper part of the 



LIVER, SPLEEN", AND PANCREAS. 



601 



renal tumor. The renal tumor, however, is not fixed. It is rounded on 
every side; it partakes of the shape of a kidney. The urine should be 
examined. 

/. Enlargements of the liver must be distinguished from pancreatic 
cyst, or effusion in the lesser peritoneal cavity. This can usually be 
accomplished with ease, except in hydatid disease of the left lobe near 
the suspensory ligament. In effusion of the lesser peritoneal cavity the 
tumor occupies the left upper quadrant, and may extend as low as the 
transverse umbilical line. It causes dislocation of the heart, so that the 
apex is as high as the third interspace, and beyond the mid-clavicular 
line. It is accompanied by an increase in the dulness posteriorly, so 
that the upper limit may extend to the angle of the left scapula. The 
results of puncture alone may be sufficient to distinguish them. 

A clue to the nature of enlargement of the liver may sometimes be 
formed by the presence or absence of pain. Murchison makes this a 
reliable distinction. Painless enlargements of the liver are due to con- 
gestion, to hydatid disease, to fatty and amyloid disease of the liver. 
Painful enlargements of the liver are seen in abscess, cancer, and syphi- 
litic disease, with perihepatitis. 

In childhood the lower border of the liver normally is lower than in 
adults, because the liver is itself proportionately larger than it becomes 
later. For the same reason the upper border is at a higher level. 

Diseases of the Liver. The Fatty Liver. 

The symptoms of fatty liver are not pronounced. The physical signs 
are those of enlargement, which is uniform and extends in all directions. 
On palpation, the edges can be felt ; they are rounded and smooth. 
They are soft at first, but later become indurated. Fatty liver may be 
followed by cirrhosis after a period of alcoholism. The general symp- 
toms are those of the primary disease. Fatty liver occurs in gouty 
subjects, but is notably present in wasting diseases, in tuberculosis, in 
chronic hip-joint disease, and in amyloid disease of the liver. 

Fatty liver sometimes follows the congestion of the liver which is 
present in the course of organic heart disease. The liver is not truly 
fatty, but properly should be called a fatty cirrhosis. There is increased 
fatty degeneration with an overgrowth of connective tissue. This form 
is associated with heart and kidney disease. On palpation the edges of 
the liver are hard or indurated. The liver may undergo diminution in 
size later, and the symptoms of cirrhosis ensue. 

Amyloid Disease of the Liver. 

Disease of the liver attended by enlargement without pain, is often 
due to amyloid disease. Similar disease is found in other organs, and 
there is present, to point to the nature of the enlargement, bone disease, 
prolonged suppuration, or tuberculosis. In amyloid disease the pallor 
of the patient is pronounced and the face may be swollen, and the 
ankles slightly (edematous. The spleen is enlarged, the urine albu- 
minous, scanty, but of moderate specific gravity. In amyloid disease 



602 



SPECIAL DIAGNOSIS. 



a history of syphilis is an important point in establishing the diag- 
nosis. Fatty liver can readily be distinguished from amyloid disease 
by palpation. In amyloid disease the surface is smooth, but it is very 
hard and indurated. 

Cancer of the Liver. 

The setiological factors upon which the diagnosis of cancer is based 
are : the age of the patient — most frequently between the fortieth and 
sixtieth year ; the female sex, in a measure, and heredity. The disease 
is nearly always secondary to cancer in some other situation, conse- 
quently in cases in which symptoms point to cancer of the liver search 
must be made for the primary lesion elsewhere. Of these the most 
frequent are the rectum, the uterus, the stomach, the remainder of the 
gastro-intestinal tract. Cases have been reported in which the eye has 
been removed for unrecognizable disease, and symptoms of carcinoma 
of the liver have subsequently developed. The nature of the hepatic 
symptoms was obscure during life, but at the post-mortem examination 
melanotic sarcoma was found ; the primary lesion was undoubtedly 
present in the eye. Further serological influences that may bear upon 
the diagnosis are: 1, the occurrence of gall-stones, which act as the 
exciting cause in the development of primary cancer of the ducts, from 
thence spreading to the liver ; 2, the occurrence of trauma. 

The symptoms of cancer of the liver are due to increase in size 
of the liver, to pressure of the growths upon the ducts or terminal 
portal vessels ; and to the general effects of carcinoma upon the 
system. The liver is enlarged and its surface irregular. The organ 
can be made out by palpation extending below the margin of the 
ribs. The edges are irregular, and, on the surface, bosses can be dis- 
tinctly felt. In rare cases one or two masses alone may be present, 
growing out of the substance of the left lobe of the liver, on account of 
which a large tumor may be seen below the sternum. The nodules are 
usually hard, but sometimes may be soft and even fluctuate. The abdo- 
men is distended. 

After emaciation becomes marked the nodules can be seen near the 
surface of the skin, and even the multiplication distinctly made out. 

The liver is movable with each inspiration ; the enlargement can be 
noted while under observation. By percussion the enlargement can be 
distinctly made out, and while the surface is irregular, the general shape 
of the dulness corresponds to that of the liver. On account of the 
increase in size and of inflammation of the capsule the patient com- 
plains of weight in the hepatic region, and of pain which may be inter- 
mitting in character. The nodules may be tender on palpation. The 
superficial veins are enlarged. 

In not every instance do we find enlargement. In some cases the 
cancer is associated with cirrhosis of the liver or may itself be of a 
nodular type which shrinks. The liver is then normal or diminished 
in size, as indicated by percussion. 

The symptoms that atteud cancer are: 1. Jaundice, which is not very 
deep unless the common duct is affected. 2. Ascites, which is always 



LIVER, SPLEEN, AND PANCREAS. 



603 



present in the atrophic forms, but may be absent when the liver is en- 
larged. 3. The general symptoms are those of emaciation, which is 
rapid ; of prostration and, in some instances, of fever. Fever of moder- 
ate degree attends the rapidly growing cases. It is usually continuous, 
but may be intermittent, especially if there is suppuration, or suppura- 
tive inflammation of the ducts. It is a well-known fact that gall-stones 
are of common occurrence in patients the subject of cancer in whatever 
location it may develop. The symptoms of biliary calculus or of ob- 
struction may attend those of secondary cancer of the liver, and the 
stones bear an ^etiological significance. 

In many instances secondary cancer of the liver may be present with- 
out symptoms during life to attract attention to this organ. If cancer 
in other regions has continued for the usual period of time, it may be 
almost certain that at the autopsy cancer of the liver will be found to 
be present. 

Diagnosis. The diagnosis of cancer of the liver is not difficult when 
the changes in the liver can be made out on palpation and percussion. 
In rare instances in which the liver is smooth it may be mistaken for 
fatty or amyloid liver. A definite cause can usually be made out for 
the latter, while the occurrence of jaundice, the rapid increase in size of 
the liver, and the general symptoms of the caucerous cachexia indicate 
the hepatic affection. The syphilitic liver with irregular guramata may 
cause serious doubt; the history of the case and other signs of syphilis 
aid in the diagnosis. Locally the condition may exactly simulate car- 
cinoma. The jaundice, however, is not so frequent in occurrence or so 
deep in syphilitic gummata ; the cachexia does not ensue, but the thera- 
peutic test may be essential in order to make a diagnosis. 

In hypertrophic cirrhosis of the liver the jaundice is deep and the 
liver enlarged ; there is but little wasting and ansemia. In this form 
of cirrhosis the surface of the liver is smooth ; certainly there are not 
any bosses, aud the organ is painless. Ascites is more common in 
cirrhosis ; the patient is usually affected earlier in life than is true in 
cancer. 

In a large growing cancer one or two of the nodules may suppurate 
and simulate abscess of the liver. In the absence of cause for the 
abscess, the age of the patient and the results of aspiration favor 
carcinoma. If the cause is dysentery, the age, early life, occurrence 
of persistent pain, irregular enlargement of the liver, the development 
of anaemia, but not of cachexia, and very marked hectic, without jaun- 
dice, favor abscess. If the enlargement is posterior it may set up 
localized pleuritis or moderate pleural effusion, as rarely occurs in 
abscess. 

Cancer of the liver may be simulated by cancer of organs in close 
proximity to the liver, as the pancreas, the pyloric end of the stomach, or 
the colon. In pyloric cancer the symptoms of dilatation of the stomach 
are present; the percussion note is not dull, but there is a dull tympany 
over the tumor ; it is attended by vomiting and possibly hemorrhage 
from the stomach. Jaundice occurs late. Cancer of the pyloric end is 
not movable with respiration unless it becomes adherent to the liver. 
Cancer of the omentum and colon are not modified by respiration. The 



604 



SPECIAL DIAGNOSIS. 



percussion note over them is different ; they frequently extend beyond 
the liver confines and are associated with symptoms of obstruction of 
the bowels. Fceoal accumulation in the transverse colon must not be 
mistaken for cancer of the liver. The large masses adjacent to the liver 
may closely simulate cancerous nodules. Careful percussion must be 
resorted to to prevent confusion. Cancer of the liver and hydatid 
disease must not be confounded. The tumor in hydatid disease is 
usually single; it is large, and may fluctuate or yield the hydatid 
fremitus. It causes enlargement of the liver, the shape of which is 
irregular when the tumor presents in the epigastrium or along the 
margin of the ribs. It is painless. Aspiration yields the characteristic 
hydatid fluid. 

Cancer of the bile-ducts cannot always be distinguished from cancer 
of the liver ; although the occurrence of early jaundice in the patient 
the subject of gall-stones, with secondary enlargement of the liver and 
gall-bladder, at first smooth and painless, afterward irregular and 
painful, may point to the true nature of the case, particularly if a 
primary nodule cannot be found elsewhere. Iu cancer of the pancreas 
there is also difficulty ; the occurrence of vomiting and of tumor in the 
mid-costal region, with the development of jaundice early, before the 
liver is enlarged or nodular, with other symptoms of cancer of the pan- 
creas, as intestinal dyspepsia and fatty stools, may point to the primary 
lesion in this organ. 

Cirrhosis of the Liver. 

A diffuse interstitial inflammation of the liver, chronic in duration, 
usually with atrophy of the organ, is caused by irritants, in the large 
majority of cases, which enter the portal circulation through the stomach. 
Of the irritants alcohol is the most common, and particularly the stronger 
liquors, as gin and whiskey. Other irritants, as spices used to excess, 
may likewise cause the diffuse inflammation. In addition, however, 
cirrhosis of the liver may follow the infectious diseases, notably scarla- 
tina, and may be incited by malaria. These forms of cirrhosis lead 
usually to atrophy of the liver. 

Another form is due to obstruction of the bile-ducts with secondary 
overgrowth of the connective tissue. It is known as hypertrophic or 
biliary cirrhosis. In addition, cirrhosis of the liver may arise in the 
course of syphilis ; the anatomical characters are different from those of 
true cirrhosis. This does not include an account of the secondary cir- 
rhosis of the liver which arises in the course of a passive congestion of 
that organ, on account of which the so-called nutmeg liver develops. 

Cirrhosis of the liver of the atrophic form, due to alcohol, presents 
various clinical features. In the first place it may exist without caus- 
ing any symptoms whatever during life. It is to be found only after 
death from other causes, or it may not present symptoms until an 
accident in the course of the disease may occur, as hemorrhage from 
some portion of the collateral circulation. In both of these instances 
the symptoms are absent because the collateral circulation is complete. 
If this is incomplete, however, grave symptoms, local and general, 
ensue. 



LIVER, SPLEEN, AND PANCREAS. 



605 



Before detailiDg them it may be well to state that the occurrence of 
one symptom which we have termed accidental may lead to the inference 
that cirrhosis of the liver is present, particularly if the patient has been 
an alcoholic. This symptom is hemorrhage. It may take place from 
the stomach, causing death at once, or after repeated hemorrhages have 
occurred ; or it may take place from the intestine. 

The Symptoms of Cirrhosis. The symptoms are general, due to inter- 
ference with the nutrition of the patient ; and local, dependent upon 
the degree of obstruction to the portal circulation. General symptoms 
rarely occur unless the local symptoms are present, which lead to mal- 
nutrition and mal-assimilation on account of interference with the gastro- 
intestinal digestion. In many instances a typical pattern of the disease 
is presented extending over a long period of time. 

The symptoms observed throughout the disease have been referred to 
as symptoms of the first stage, or stage of enlargement, and symptoms 
of the second stage, or that of contraction. During the first stage the 
symptoms are those of gastritis, with enlargement of the liver. This 
so-called first stage is not always observed. 

The gastric symptoms are those of morning retching or vomiting, 
with discharge of mucus, associated with other symptoms of gastric 
catarrh, as the loss of appetite, nausea, tenderness in the epigastrium, 
eructations, and constipation, with which symptoms the health may 
fail. The liver is enlarged and the outline regular. During the second 
stage more severe symptoms arise, due to obstruction of the portal 
capillaries. 

The Signs of Portal Obstruction. The abdomen becomes distended 
and the sensation of weight and pressure is complained of. On exam- 
ination ascites is detected. This may become enormous, causing mon- 
strous distention with pouting of the umbilicus. The spleen is found to 
be enlarged, extending over twice or three times the normal area on 
percussion. If ascites does not interfere, the edge of the spleen can 
be readily made out. The portal obstruction causes secondary gastro 
intestinal catarrh, if it had not already been present on account of the 
alcoholism. Although constipation is usually present, there may be 
persistent diarrhoea. This may occur in the mornings only, and it may 
be lienteric. Hemorrhages may take place from the gastro-intestinal 
tract at any time either from the stomach or the intestine. Not infre- 
quently they occur from the oesophagus, due to varicosity of the veins at 
the junction of the oesophagus and cardiac end of the stomach. Hemor- 
rhoids are always present and may bleed at each stool. Jaundice is 
usually not the rule, and, it present, is usually light and generally due 
to the duodenal catarrh. The skin is of yellowish tinge or of a grayish- 
earthen color only. 

Physical Examination. This may be rendered difficult on account of 
the large amount of ascites before paracentesis is performed. Early in 
the disease the enlarged liver of the first stage will be found to have 
undergone contraction, although diminution in the area of dulness is not 
by any means as absolutely confirmative of contraction as the opposite 
condition is of hypertrophy. Percussion should be performed several 
times, because the distended intestinal coils may modify the results. 



606 



SPECIAL DIAGNOSIS. 



Symptoms. The general symptoms of cirrhosis, and particularly 
the symptoms of the later stages, are striking and diagnostic. The 
nutrition is much impaired. The patient, who in the large majority of 
cases was at one time corpulent, becomes emaciated. The skin changes 
in color and becomes of an earthy-gray or dirty-sallow hue. The capil- 
lary venules of the face are dilated ; the distended capillaries on the nose 
are distinct. Later, ecchymoses may occur in the skin and hemorrhages 
take place from the mucous membrane and into the retina. Debility 
ensues; oedema of the ankles is almost sure to occur, and sometimes 
general anasarca may take place. It is extremely rare to have fever 
unless complications occur. The pulse is small and becomes more rapid 
than normal ; the heart sounds grow weaker. In the later stages the 
skin may be the seat of eruptions and chronic skin diseases of various 
kinds develop. 

The urine throughout the disease presents no characteristics; as 
ascites develops it becomes scanty and dark, is loaded with urates and 
uric acid. In rare instances it may contain sugar, and if the uric acid 
is in excess, albumin. 

With the distention of the abdomen enlargement of the superficial 
veins is also observed. This may be very pronounced, and particularly 
about the umbilicus. The enlarged swollen mass in this situation has 
been called, from its appearance, the caput Medusae. 

Collateral Circulation. The collateral circulation that develops in 
order that the portal blood may reach the right heart takes place in 
various ways. First, communication may be formed between the veins 
of the mesentery and those of the abdominal walls ; second, between the 
coronary veins of the stomach and the veins of Glisson's capsule and the 
phrenic veins ; third, between the internal hemorrhoidal and the hypo- 
gastric veins ; fourth, enlargement of the obliterated umbilical vein in 
the ligamentum teres may take place. 

In the study of a case of cirrhosis of the liver a judgment as to its 
nature may be in a measure confirmed by the presence of other phe- 
nomena due to the same cause. Very frequently we have at the same 
time cirrhosis of the kidneys and sclerosis of the arteries, with second- 
ary atheroma, both of which have led to hypertrophy of the heart. 
Striimpell refers to the occurrence of cirrhosis and chronic tubercular 
peritonitis. He thinks the former is the primary lesion which predis- 
poses to the development of the latter. The course of the disease is 
prolouged. 

The duration cannot accurately be determined, as the onset is usually 
insidious. After the ascites appears the duration may vary from six to 
eighteen months. Of course this depends largely upon the degree of 
completion of the compensatory circulation. Death usually occurs 
from intercurrent disease or progressive exhaustion. In not a few cases 
cerebral symptoms occur. In addition to the cirrhotic cachexia, the 
sudden occurence of coma and convulsions, preceded by delirium, may 
ensue, the cause of which is not fully known. It must be borne in 
mind that the occurrence of these symptoms in an alcoholic subject 
may be due to a cirrhosis the presence of which had not been suspected 
during life. 



LIVER, SPLEEN, AND PANCREAS. 



607 



Diagnosis. The diagnosis is usually not difficult if the complete 
picture of the case is presented. It cannot be established positively 
without definite knowledge of the cause. If the patient comes under 
observation after ascites has developed the diagnosis is more difficult. 
It must in the majority of cases be based upon exclusion of heart, lung, 
and kidney disease. The recognition of ascites of hepatic origin depends 
upon the history and the development of the disease. Ascites may be due 
to other causes within the abdomen. It may probably be difficult to 
exclude chronic peritonitis, which is a common cause of ascites. The 
general tenderness, the less degree of distention of the abdomen, and 
the absence of eulargement of the spleen point to peritonitis. The 
fatty cirrhotic liver may present symptoms similar to those of the 
atrophic form, except that it is enlarged at the time of the examination. 

Hypertrophic cirrhosis, or so-called biliary cirrhosis, presents a some- 
what different picture. In the first place the cause is different. It has 
usually been preceded by gall-stones, or by obstruction of the duct from 
other causes. The liver is enlarged, the surface is irregular. The 
induration of the uniformly enlarged liver is most striking. The 
enlargement causes weight and fulness, aud is associated with weakness 
and loss of appetite. Jaundice very early ensues, or may have been 
the first symptom to call attention to the liver. It increases and per- 
sists throughout the course of the disease. Ascites is not usually pres- 
ent, or may be very slight. The enlargement and jaundice may 
coutinue for months or even years without the development of grave 
symptoms. 

Fever may, however, set in at any time, in all probability generally 
due to the biliary obstruction. The fever is continuous ; the tempera- 
ture rises from 102° to 104°; the tongue becomes dry and brown ; the 
pulse rapid. All the symptoms of febrile jaundice ensue. On the 
other hand, in the course of the disease the patient may be seized with 
convulsions, followed by coma and death. Most authorities state that 
the enlargement persists throughout the course of the disease, but other 
observers state that for a long period of enlargement with jaundice, if 
nervous symptoms or fever do not set in, contraction of the liver takes 
place, with subsequent development of the symptoms of portal obstruc- 
tion. At this period the spleen may become enlarged and ascites take 
place, while the symptoms of digestive disturbances become more 
prominent. Nervous symptoms that arise may be due to acute diffuse 
necrosis setting in in the course of the disease. 

The diagnosis is often difficult. Gradual and persistent jaundice 
without cause, continuing over a long duration of time, associated with 
persistent enlargement of the liver without symptoms of portal obstruc- 
tion in the non-alcoholic subject, point pretty certainly to hypertrophic 
cirrhosis of the liver. 

Syphilitic Disease of the Liver. 

Syphilitic disease of the liver may result in cirrhosis on the one hand, 
or in the development of gummata. Syphilitic cheilosis presents the 
same symptoms as the alcoholic form. The history, the more marked 



608 



SPECIAL DIAGNOSIS. 



irregularity on the surface or the edge of the liver, and the existence 
of syphilis elsewhere may lead to a diagnosis of the true condition. 

In congenital syphilitic disease of the liver the inflammation is diffuse; 
the liver is enlarged and hard ; the surface is smooth ; there are usually 
syphilitic lesions in other organs; the patient presents syphilitic eruptions, 
and has the well-known wizened appearance that belongs to this affection. 

Syphilitic gummata in the liver may exist without presenting any 
symptoms whatsoever, or their presence is known by the occurrence of 
pain and a localized swelling and discomfort, which calls the patient's 
attention to the region, particularly if at the same time the patient's 
health is reduced. Tumors are situated in the left lobe, in the median 
line, or along the margin of the ribs. Pain is usually localized to this 
region, but may extend over more or less of the liver, particularly if 
there is general perihepatitis along with other evidences of syphilis, 
which however may not be present. If the temperature is taken fre- 
quently a moderate febrile range will be observed. It may not rise above 
100 J°, but in the absence of other causes is a valuable diagnostic symp- 
tom. In other instances the gummata may grow in such a situation as 
to interfere with the portal circulation or press upon the gall- ducts. The 
latter is very rare. If the gummata are felt, they are enlarged bosses 
which give the sensation of flattened hemispheres. Sometimes on the 
surface of the enlarged organ several separate elevations can be made 
out. To determine the exact nature of the lesion is often very difficult. 
The symptoms may conclusively point to hepatic disease. Knowledge 
of the occurrence of syphilis or alcoholism may influence the decision. 
If with the syphilitic history there are scars in the throat, nodes on the 
bones, or other signs of syphilis, the conclusion will be modified by 
these findings. Severe pain is more prominent in syphilis than in cir- 
rhosis, and the nodules of syphilis are markedly in contrast with the 
granular surface of cirrhosis. 

Abscess of the Liver. 

Two forms are seen : tropical abscess, so called, in which one or two 
abscesses are found ; and multiple abscesses, found throughout the liver 
structure. The single or solitary abscess usually occurs in the course 
of dysentery, and in all probability in the amoebic form only. A single 
abscess may also be due to traumatism, particularly in children. Mul- 
tiple abscesses occur secondarily to inflammation somewhere in the 
portal area. Inflammation and abscess about the rectum, inflammation 
of the appendix, ulceration anywhere in the gastro-intestinal tract may 
be followed by multiple hepatic abscesses. The abscesses, however, do 
not occur directly by means of emboli, as in the case of amoebic abscess, 
but after inflammation of the portal vein or suppurative pylephlebitis. 
Multiple abscesses of the liver also follow obstruction and suppurative 
inflammation of the biliary passages {suppurative cholangitis). 

Tropical abscess, or amoebic abscess varies in its clinical course. In 
a typical case the clinical picture is that of the general symptoms of 
suppuration setting in in the course of or soon after an exacerbation of 
amoebic dysentery, with local symptoms referred to the liver. 



LIVER, SPLEEN, AND PANCREAS. 



609 



Symptoms. The general symptoms are those of intermittent fever, 
paroxysms of which may occur daily or only every second day, and in 
which chill, fever and sweat occur. The fever may be remittent or 
may be continuous. 

The local symptoms. Pain in the region of the liver ; this may be 
referred to the region of the right or the left lobe. It may be seated 
in the fifth or sixth interspaces anteriorly, or behind at the ninth and 
tenth ribs. There may be pain in the right shoulder. The pain may 
be paroxysmal, or it may be intense and persistent. 

Fig. 89. 




Intermittent fever in abscess of the liver. 



Physical Examination. On examination the liver is enlarged. The 
enlargement may be uniform ; if the abscess is central the entire organ 
takes part in the swelling ; on the other hand it may be an enlarge- 
ment upward in the anterior, the axillary, or the posterior region. If 
the convex surface of the right lobe of the liver is affected the enlarge- 
ment is usually upward. If the lower portion of the right lobe is 
affected, enlargement extends downward, and the lobe of the liver can 
readily be detected on palpation. The mass may extend outward from 
the liver edge. At first it is hard and indurated ; ultimately it softens 
and may fluctuate. If the abscess is limited to the left lobe of the 
liver, and is situated about the suspensory ligament, the enlargement 
may be seen below the xiphoid cartilage. It may extend to the umbil- 
icus and project forward to a great degree. Sometimes it may be so 
large as to cause eversion of the ribs of each side, and the entire epi- 

39 



610 



SPECIAL DIAGNOSIS. 



gastriurn be unusually prominent. The surface may become reddened. 
Over the tumor there is tenderness on palpation, and there may be, as in 
other situations, fluctuation. (Edema of the surface is frequently seen. 

The irregular enlargement above mentioned is made out by per- 
cussion. The enlargement may be difficult to ascertain on account of 
secondary pleural effusion, or secondary pleural inflammation with the 
development of a hepato-pulmonary fistula, on account of which dulness 
is created posteriorly. If the case has been seen from the first, a friction 
sound may precede the development of the pleural complication, and 
the physical signs of effusion gradually develop while under observation. 

The patient complains of weight and fulness in the region of the 
liver ; the enlargement causes some dyspnoea ; cough is of frequent 
occurreuce, and from the enlargement or from the septic symptoms 
there may be vomiting. The appetite is lost, and nausea at the sight of 
food is prominent. The condition of the bowels may vary with the 
state of the intestinal tract at the time of the hepatic complication. The 
dysenteric symptoms may subside entirely or they may continue. Often 
there is constipation, with the passage of mucus and hardened faeces 
only. In an obscure case a study of the stools may be made. The 
detection of amoebae in the mucus or in the intestinal discharge may 
point to the true conclusion. 

Atypical cases are characterized by the absence of general symptoms, 
or the absence of local signs. Fever may be absent entirely, exhaustion 
alone being present, which could properly be ascribed to the previous 
dysentery. Pronounced anaemia due to the dysentery may be associated, 
as well as rheumatic inflammation of the joints, or neuritis. In a case 
under my care, with the exception of anaemia and loss of appetite the 
only symptom for a long time was severe pain in the sixth interspace. 
In other instances there are no liver symptoms whatsoever. General 
symptoms of suppuration or an irregular fever, or even a continued 
fever the cause of which cannot be ascertained, may alone be present. 
In one of my cases there was moderate continued fever, with loss of 
appetite and dyspeptic symptoms. There was no diarrhoea. ~No cause 
could be given for the fever, although it was noted that there was slight 
enlargement of the liver. The patient slipped out of the ward and 
went down to the yard to smoke ; on his return he was seized with an 
intestinal hemorrhage which could not be checked and which resulted 
fatally. At the autopsy a large abscess of the liver was found, and 
there was ulceration of the rectum from which the intestinal hemorrhage 
took place. 

The diagnosis is not difficult usually in the typical cases. Under all 
circumstances attention must be paid to the facts bearing upon etiology 
and the association of general and local symptoms. If the general 
symptoms of suppuration are present abscess may be mistaken for an 
intermittent fever. The results of an examination of the blood and of 
treatment by quinine would establish a diagnosis of the malarial fever. 
It is difficult sometimes to determine whether the abscess is in the 
abdomiual wall or in the liver proper, or whether it is situated beneath 
the diaphragm. If the liver is movable with respiration, the two other 
conditions may be excluded. An abscess in the abdominal wall is not 



LIVER, SPLEEN, AND PANCREAS. 



611 



influenced by respiration, and in sub-diaphragmatic abscess the move- 
ment is impaired. Suppuration of an hydatid cyst cannot be dis- 
tinguished unless it has been known beforehand that a simple hydatid 
was present in the liver. Under such circumstances if suppuration 
arises, the probability of its being confined to the cyst is very great. 
Abscess of the liver must be distinguished from gall-stones, which are 
attended by intermitting fever without suppuration. While the dis- 
tinction is difficult in many cases, yet the history of the case, the 
association of jaundice which deepens after each paroxysm, and the 
good general nutrition of the patient point to the latter. Abscess of 
the liver is of shorter duration than the former, and the primary cause 
of it can usually be ascertained upon examination of the rectum or 
upon the determination of suppuration in other parts of the body. 

Exploratory puncture must be resorted to in many cases, and usually 
can be done with safety. Puncture must be made over the region in 
which the enlargement is greatest, or at which the swelling is most 
prominent. In abscess secondary to dysentery, a brownish-colored pus 
will be withdrawn resembling anchovy sauce. It may be of a peculiar 
odor, and on examination amoebae common to this form of dysentery 
may be found If there is no point of election, the needle may be 
entered in the lowest interspace in the anterior axillary or the seventh 
interspace in the mid-axillary line. A fairly large sized aspirator 
should be used. Suppuration may be present, and yet not be reached 
by aspiration. 

The complexion in tropical abscess of the liver is peculiar, and has 
been insisted upon by all writers upon tropical diseases. The skin is 
sallow, the complexion muddy, the face pale. Through this a slightly 
icteroid tint may be seen, and the conjunctiva? are bile-tinged. Jaundice 
is of rare occurrence. 

Abscess of the liver may also be due to pyaemia. It may be a part 
of general pyaemia or, as previously mentioned, of portal pyaemia. Para- 
sites and foreign bodies, as well as gall-stones, may excite an abscess. 

The echinococcus cyst may suppurate, or round-worms may penetrate 
to the liver and cause suppuration. 

The symptoms of suppurative pylephlebitis and of pyemic abscess are 
general and local. Jaundice is more common than in solitary abscess, 
and there is greater pain and tenderness over the liver, which is 
uniformly enlarged and tender. With the enlargement of the liver and 
jaundice we have the symptoms of pyaemia. They are not peculiar. 
Sometimes the fever is distinctly intermitting, or it may be irregular 
and septic in character. 

The symptoms of solitary abscess of the liver, as has been previously 
stated, may be obscure, and attention be called to the liver only when 
symptoms due to a rupture in the neighboring organs may arise. If 
perforation takes place into the peritoneum it is not likely that the cause 
can be established during life. A frequent direction in which the 
extension takes place is through the diaphragm to the pleura, then to the 
lung. An empyema may be set up, the true source of which may not 
be ascertained unless an examination of the pus is made. The physical 
signs are those of empyema — dulness or diminished resonance, absence 



612 



SPECIAL DIAGNOSIS. 



of fremitus and vocal resonance, diminished breath-sounds, and lessened 
movemeut, with the occurrence of symptoms of cough aud dyspnoea. 
When the lung is infected the physical signs may resemble those of con- 
solidation. There are dulness, bronchial breathing, and increased tactile 
fremitus. A harassing convulsive cough occurs, and sooner or later 
expectoration of a reddish -brown, brickdust-colored material which 
resembles anchovy sauce. This characteristic expectoration is decisive. 
Amcebse are found, and, in addition to blood pigment and corpuscles, 
orange-red crystals of hsemajtoidin, cholesterin plates, and leucin and 
tyrosin may be seen. When the abscess perforates into the stomach or 
bowel the discharge from either cavity may be of the above-mentioned 
nature. Perforation into the pericardium is followed usually by imme- 
diate death. 

Hydatid Disease of the Liver. 

Hydatid disease is comparatively rare in this country, and yet, 
without doubt, at least from my own experience, is increasing in 
frequency. Without an increase in the opportunities for observation, 
I have seen seven cases within the last two years, compared to the 
same number during the five previous years. The disease occurs 
in people who are associated with dogs. It may occur at any age, 
but is most common in adult life. It is very rare before the 
fifth year. The symptoms are local, depending upon the size of the 
tumor. Small cysts may be present without any disturbance. Large 
and growing cysts cause signs of tumor, with great increase in the size 
of the liver. The physical signs depend upon the situation of the tumor. 
It may be found in the median line above the umbilicus, causing a dis- 
tinct prominence, tense and firm, which sometimes yields fluctuation. 
Quite often the tumor grows at the suspensory ligament, pushing the 
diaphragm upward, dislocating the heart, and causing an increased area 
of dulness in the left upper quadrant. In this position it may simulate 
a pancreatic cyst or effusion in the lesser peritoneal cavity. If the tumor 
is in the right lobe the enlargement of the liver may be upward or 
downward. The upper border of liver dulness may begin two or three 
interspaces higher than normal posteriorly or in the axillary region. 
If the cysts are superficial when palpated with the fingers of the left 
hand and percussed with the right, a vibration or trembling movement 
is felt, which may continue for a certain time. It is known as the 
hydatid fremitus. It is not always present. The enlargement is pain- 
less. Local sensations of weight and dragging may be complained of. 
If suppuration sets in there may be considerable pain. 

The general symptoms are negative ; the nutrition does not suffer 
unless the enlarged mass interferes with physiological acts of digestion and 
assimilation by pressure. If suppuration sets in the general symptoms 
of abscess of the liver arise. Jaundice is more common than in tropical 
abscess. The abscess may perforate into one of the adjacent hollow 
viscera, or into the pleura and brouchi. It may perforate externally. 
It may perforate into the pericardium or vena cava, and cause death. 
If perforation takes place in the biliary passages obstructive jaundice 



LIVER, SPLEEN", AND PANCREAS. 



613 



arises, with secondary suppurative cholangitis. When the cysts rupture, 
or if they are aspirated, an eruptiou of urticaria may break out. This 
is not of diagnostic significance, except that it may point to rupture of 
the cyst. 

Diagnosis. The diaguosis is not difficult. The occurrence of irreg- 
ular, painless enlargement of the liver without general symptoms is 
significant. If fluctuation is detected, or the fremitus, a more positive 
conclusion can be reached. When suppuration takes place the symptoms 




Human echinococci. (From Finlayson, after Davaine.) 

A, a group of echinococci, still adhering to the germinal membrane by their pedicles. X 40. 

B, an echinococcus with head invaginated in the body, x 107. 

C, the same compressed, showing the suckers and hooks of the retracted head. 

D, echinococcus with head protruded. 

E, crown of hooks, showing the two circles. X 350. 



Fig. 91. 



4S 



Hooks from taenia echinococcus. X 350. 

are like those of abscess of the liver. Hydatid disease must be distin- 
tinguished from syphilitic hepatitis, in which there is irregular enlarge- 
ment. The enlargement is hard and does not fluctuate. Sometimes 
the symptoms resemble cancer, but the age of the patient, the occurrence 
of jaundice, the extreme emaciation and cachexia look to that affection 
rather than to hydatid disease. Enlargement of the gall-bladder contain- 
ing a mucoid fluid, in which fluctuation can be detected, may simulate 
hydatid disease. The enlargement, however, may be preceded by con- 



614 



SPECIAL DIAGNOSIS. 



ditions which cause obstruction of the cystic duct. The gall-bladder is 
movable. In some instances there may be resonance between it and 
the liver. It is of a pyriform or oblong shape usually. In hydro- 
nephrosis the symptoms of a localized cyst are present. It does not 
move with respiration, as in hydatid disease ; is attended by symptoms 
of renal disease; the results of exploratory puncture must occasionally 
be awaited before a diagnosis can be established. A hydatid cyst may 
frequently be confounded with pleural effusion of the right side. The 
physical signs of effusion at the right base may be present. The dis- 
tinction may be made by the character of the line of dulness. In 
hydatid cyst, as Frerichs points out, it is a curved line, the greatest 
height of which is found in the scapular region. It is not difficult 
usually to distinguish hydatid cyst from other forms of painless en- 
largement. In fatty and amyloid disease the enlargement is uniform. 
Both are of common occurrence in individuals of previous ill health, 
whereas hydatid disease occurs in healthy individuals. 

An absolute diagnosis of hydatid disease is formed upon the results 
of exploratory puncture. When this is made over a tumor, or the 
centre of dulness, if it is due to hydatid disease a clear fluid, slightly 
opalescent, is withdrawn. The fluid is of a specific gravity of 1005 to 
1018 ; it is of neutral reaction, does not contain albumin, but contains 
chlorides and sometimes traces of sugar. Hooklets may be found in 
the clear fluid. 

Diseases of the Gall-ducts. 

Catarrhal Jaundice. This is due to inflammation and obstruction 
of the terminal portions of the common bile-duct. But few words need 
be said, as it has been referred to frequently in speaking of jaundice. 
The symptoms are those of jaundice in moderate degree, occurring co- 
incidentally with or following in a few days upon an attack of acute 
gastritis. The disease may occur in epidemic form. The onset is more 
severe, attended by chill and fever, with headache and vomiting. The 
temperature does not go beyond 102°. All the signs of obstructive 
jaundice are present. The liver is normal in size or slightly enlarged 
and tender. The jaundice continues from four to eight weeks, but 
may disappear in a shorter time. The first sign of the relief to the 
symptoms is shown in change in the appearance of the stools. The clay- 
colored stools disappear and the normal color returns. The affection, 
especially the epidemic form, usually occurs in young subjects. 

The diagnosis is based upon the age, the association of the jaundice 
with gastritis, for which frequently a definite cause can be ascertained, 
and the absence of organic heart disease, or any lesion within the body, 
on account of which jaundice might arise ; the moderate degree of jaun- 
dice, the absence of emaciation and symptoms of portal obstruction, the 
occurrence of moderate enlargement without pain. It must not be for- 
gotten that jaundice due to obstruction from gall-stones, or to pressure 
from tumors outside of the duct, is characterized in its onset by phenomena 
similar to those just mentioned. It is often necessary to wait before 
an opinion can be given, although a history of the previous attacks of 



LIVER, SPLEEN", AND PANCREAS. 



615 



jaundice and the age of the patient, after forty, also lead to caution in 
the diagnosis. 

Gall-stones. Gall-stones form in the biliary passages and may 
remain therein without creating symptoms, or in the effort at passage 
cause attacks of pain called hepatic or biliary colic, after which the stone 
may pass into the intestinal tract without further hepatic symptoms. 
It may become obstructed in the biliary canal and set up catarrhal or 
suppurative inflammation, which in turn is followed by stricture in 
many cases. Gall-stones usually form or at least show signs of their 
presence in patients after forty, most frequently in women and in 
people who have led a sedentary life and partaken of rich and indi- 
gestible food. Individuals in different generations of the same family 
are predisposed to them. 

Hepatic Colic. The passage of a gall-stone may be attended by a 
slight amount of pain only, so that if not in the right upper quadrant it 
would pass for an attack of simple indigestion. In the large majority 
of cases the pain is severe. The attack may be preceded by bilious- 
ness or indigestiou for twenty-four hours, and moderate pains or a sense 
of weight and fulness in the liver. It frequently follows the taking of 
food. Ringing in the ears, disturbance of vision, or undue flushings 
are said to precede it in some instances. 

The attack may be sudden. The patient is seized with pain which is 
usually complained of aloug the margin of the ribs at the right border, 
or there may be pain above the ribs over the liver, and in the right 
shoulder at the same time. From the hepatic region it extends to the 
median line. It may be most pronounced in this locality from the 
first. The pain is intense and paroxysmal. The patient is doubled up 
in agony. It causes more or less collapse. The pulse increases. Vom- 
iting usually occurs at the same time, first of the contents of the 
stomach, then a yellowish bile-stained fluid. The vomiting may be 
extreme, so that the patient is tormented by the pain, the retching, and 
vomiting. The attack sometimes disappears as suddenly as it occurred, 
or wears off gradually. When most severe the symptoms of shock 
follow. The bowels are not disturbed during the attack. The urine 
may become suppressed ; it is high-colored. After the attack it may 
contain bile. 

At the time of the attack there is considerable tenderness below the 
xiphoid cartilage and in the hepatic region. The tenderness is more 
marked when deep pressure is made in the gall-bladder region and to the 
right of the mid-clavicular line, at the margin of the ribs. The epigas- 
trium may be slightly swollen. The tenderness persists after the attack, 
and the stomach may be weak and irritable for some time ; pain, however, 
is usually removed at once. The attack may frequently recur until the 
stone has been passed, so that in twenty-four hours the patient may 
have a dozen or more attacks. When the attacks have subsided light 
jaundice may supervene, which usually does not continue more than a 
week at the furthest, during which there are also symptoms of mild 
gastritis. 

In some instances a chill precedes the pain, or immediately follows it, 
after which the temperature rises. When the paroxysm subsides the 



616 



SPECIAL DIAGNOSIS. 



fever disappears rapidly, being followed by profuse perspiration. If the 
gall-stones have set up catarrhal inflammation moderate fever may con- 
tinue for a few days. 

During the paroxysms of hepatic colic a gall-stone may be passed. 
It is desirable to determine this if possible. This can only be done by 
careful examination of the faeces by placing them in a sieve and pouring 
water upon them until they become soluble. Instead of gall-stones, 
dark-colored granular bile, which has become inspissated, is sometimes 
seen in the motions. This character of bile gives rise to as much pain, 
according to Harley, as true biliary concretions. If the stone is not 
passed it may fall back into the gall-bladder and not cause further 
symptoms for a time, or become impacted in the ducts. The impaction 
may be such that obstruction is not caused by its position, the bile 
being forced through or around it, or complete obstruction may take 
place. (See Jaundice.) 

Obstktjction of the Ducts. The symptoms from obstruction 
depend upon its seat. If the obstruction is in the cystic duct the gall- 
bladder enlarges. The liver is not secondarily affected. The enlarge- 
ment is noted at the edge of the liver in the usual situation, and may 
gradually increase to an enormous extent, so that it has been mistaken 
for an ovarian cyst. The gall-bladder is often quite movable, and on 
account of its location and movability, as well as its long shape, has 
been taken for a floating or movable kidney. If not too large, when 
the hand is placed over it and along the margin of the liver on careful 
deep palpation, if the patient takes a full breath, the rounded or pyri- 
form mass can be felt to swell underneath the palpating fingers. The 
enlargement is not attended by other symptoms except mechanical, 
unless the contents of the gall-bladder are purulent. In obstruction 
with simple enlargement the fluid of the gall-bladder, should aspiration 
be performed, is thin, of a mucoid nature, alkaline in reaction. It may 
contain cholesterin plates, and sometimes blood. It must be distin- 
guished from the fluid of an hydatid cyst. 

A cute phlegmonous inflammation of the gall-bladder may take place 
attended by localized pain and tenderness, by high temperature, extreme 
prostration, and the rapid development of the typhoid state. Periton- 
itis rapidly ensues. It could not be distinguished from other forms of 
acute inflammation in the same region, unless there was (1) a history 
of gall-stones; (2) tumor of the gall-bladder before the attack devel- 
oped. Suppurative inflammation of the gall-bladder may occur The 
enlargement may increase, the tumor becoming tender and painful on 
palpation. The direction of growth is toward the umbilicus. The 
general symptoms are those of suppuration. Hectic fever or markedly 
remittent fever occurs, and unless surgical relief is given peritonitis 
from infection or from rupture takes place. This may be suspected by 
the occurrence of collapse and increase in extent of the local symptoms. 

Tumors of the gall-bladder, usually due to cystic obstruction, as pre- 
viously mentioned, may be mistaken for floating kidney, for tumor of 
the pylorus, and for ovarian cyst. 

Tumors of the gall-bladder from either of the above-mentioned 
causes are recognized by their position and shape, and by the character 



LIVER, SPLEEN, AND PANCREAS. 



617 



of the tumor. The position varies. The usual site is in the gall- 
bladder region, but it may extend as low as the groin, or may be so 
large as to distend the ribs and fill almost the entire abdominal cavity. 
If the case, however, has been under observation the tumor originally 
would have been found upon search in the gall-bladder region, the 
location of which is fairly definitely settled : this is the point corre- 
sponding to the bisection of the border of the ribs by a line drawn 
from the acromion process of the right shoulder to the umbilicus. 
From this point the tumor grows toward the umbilicus in nearly all 
the cases. The shape is pyriform or globular, and can be recognized 
by this shape. The character of the tumor varies. It is usually 
tender, firm, but elastic on pressure aud movable. Fluctuation may 
often be detected. If the enlarged gall-bladder contains calculi they 
may be felt as small, hard masses which cause a grating sensation to be 
transmitted to the finger. On aspiration, if the cystic duct is obstructed, 
the mucoid fluid previously mentioned, or pus, is withdrawn. If the 
common duct is obstructed bile would pass through the trocar. 

The enlargement must be distinguished from tumors of the liver, of 
the stomach, duodenum, pancreas, or lymphatic glands. Tumors of 
the liver are usually due to carcinoma. They are multiple, associated 
with enlargement of the liver, with jaundice, ascites, enlargement of 
the spleen, and emaciation. Tumors of the stomach, duodenum, and 
pancreas are in a different position, and are attended by functional dis- 
turbance of the respective organs from which they spring. An abscess 
of the liver may simulate enlargement of the gall-bladder if puru- 
lent. If the abscess can be palpated an area of induration is first felt, 
followed afterward by softening and fluctuation of the swelling. In 
judging of the true nature of the tumor consideration of the causes of 
abscess must be made. In hydatid disease the tumor develops slowly ; 
it is painless; it may yield fremitus, and if movable the course is slow 
and not attended by general symptoms. Mullilocular hydatid disease 
can rarely be distinguished save in the difference of the position of the 
tumor. It is nodulated, hard, and tender, but is associated with jaun- 
dice, ascites, oedema of the legs, enlarged spleen, and great emaciation 
and prostration, with rapid decline of the patient. A syphilitic gumma 
in the liver may occupy the region of the gall-bladder. It can usually 
be made out as continuous with the liver structure. It is tender and 
painful, but irregular ; other signs of syphilis, or a history of the 
infection and of symptoms of a primary and secondary period will aid 
in the distinction of the disease. 

Floating kidney. The gall-bladder is larger and more movable at 
one end than the other ; whereas the entire kiduey is movable. The 
gall-bladder may fluctuate and the mass is associated with symptoms 
of hepatic disease. On the other hand, the well-known symptoms of 
floating kidney, the shape of the tumor, the sensation of nausea secured 
by palpation, point to the renal origin of the mass. Tumors of the 
kidney must be distinguished, such as sarcoma, hydronephrosis, and 
pyonephrosis. 1. There may be changes in the urine. 2. In renal 
tumors the intestine is in front of some portion of them, or a zone 
of resonance is found between the liver dulness and the tumor. 3. 



618 



SPECIAL DIAGNOSIS. 



Renal tumors are fixed. They may, as in hydronephrosis, come and go, 
preceded by attacks of renal colic and attended by anuria. From 
ovarian or uterine tumors the diagnosis must be made by examination 
of the genital organs. 

Enlargement of the gall-bladder on account of calculous obstruction 
must be distinguished from enlargement due to cancer of that organ. 
This is often difficult and cannot be done without having the patient 
under observation for a long period of time. Cancer of the gall- 
bladder is usually primary. It may begin in the gall-ducts. In the 
larger number of cases it occurs in patients who have had gall-stones. 
It is found most frequently in females, and after the fiftieth year. 
Tight lacing or pressure around the abdomen may predispose to it. 
The symptoms are those of pain, jaundice, emaciation, cachexia, and the 
presence of a tumor. The pain is localized and lancinating in character. 
Jaundice occurs in 70 per cent, of the cases, and gradually increases in 
intensity. The tumor is situated in the gall-bladder region, to the right 
of the umbilicus. It is hard or firm, painful, and the seat of tenderness. 
The tumor is fixed. Sometimes the disease is found in the cystic duct, 
and then the gall-bladder is enlarged. As the history of gall-stones is 
of frequent occurrence in both instances, it is impossible to distinguish 
the two forms of obstruction causing enlargement, save that in carci- 
noma the emaciation and cachexia may point to the true nature of the 
case. In tumor of the gall-bladder due to cancer, the secondary effects 
on the liver are usually more marked than in tumor from other causes. 
The liver enlarges and its surface becomes irregular or nodular. 

Obstruction of the common duct by gall-stones, (a) In addition to 
jaundice, paroxysms of chill, fever, and sweat occur, with catarrhal 
inflammation of the biliary passages. (1) The paroxysms resemble 
intermittent fever ; (2) the jaundice may continue for years and deepen 
after each paroxysm ; (3) with the paroxysm, hepatic colic may occur ; 
(4) health fails but slightly. The paroxysms may occur daily, or 
only once a week, or they may be tertian and quartan in type. On 
account of the obstruction in this situation the liver becomes enlarged. 
It is firm and smooth on palpation. The enlargement, as determined 
by percussion, is uniform. (6) Gall-stones may cause suppurative 
inflammation of the biliary ducts, just as suppuration of the gall-bladder 
may ensue. The symptoms, both general and local, are pronounced. 
The fever may be intermittent, but is more likely remittent ; jaundice 
is present, but constant in its intensity. The local signs of enlargement 
and tenderness are made out. The patients die of exhaustion or sep- 
ticemia. Sometimes the gall-bladder ruptures into the stomach or 
colon, and temporary abeyance of the symptoms may result. 

The Accidents of Grall-stones. While the effects just noted of the 
presence of stones in the biliary passages may rightly be considered as 
accidents, nevertheless their occurrence is so common as to be part and 
parcel of the history of gall-stones. As accidents, we have the forma- 
tion of biliary fistula, with passage of the gall-stone into the contig- 
uous organs or channels. The stoue may ulcerate into the gall-bladder 
from one of the ducts, may perforate the portal vein, may perforate 
into the abdominal cavity — the most frequent accident. Perforation is 



LIVER, SPLEEN, AND PANCREAS. 



619 



of common occurrence also into the duodenum, iuto the colon, and 
rarely into the stomach. The occurrence of such perforation can 
only be assumed by its secondary effects : (1) An attack of gall- 
stones ; (2) local inflammation with fever; (3) the occurrence of peri- 
tonitis, or the discharge of pus by the bowels, or by vomiting. That 
it is due to gall-stones is proven in those rare instances in which the 
stone is passed per rectum. Often it may be impacted in the intestinal 
canal, causing the symptoms of acute obstruction, or in the rectum, 
causing local tormina and tenesmus. The perforation, however, occurs 
in other directions. Sometimes fistulous connection is formed between 
the gall-bladder and the urinary passages, calculi and pus being dis- 
charged from the urine. In other instances fistula? between the bile 
passages and the lungs take place. The bile is coughed up and expec- 
torated sometimes with small calculi. The most common form is 
for the ulceration to take place toward the surface with the formation 
of cutaneous fistula. After the fistula has opened externally gall-stones 
in large numbers may be passed. If not, the diagnosis of the cause 
of the fistula must be based upon the history and the results of investi- 
gation by probe, with attention to the condition of the other organs. 

Symptoms. In stenosis of the bile-ducts the chief symptom is that 
of jaundice. Colicky pains occurring in paroxysms, intermittent 
jaundice varying in intensity, and an intermittent fever, point to gall- 
stones. If the obstruction is due to disease outside of the ducts its 
nature must be inferred by the symptoms and physical signs of disease 
in neighboring structures. If the jaundice is due to enlargement of the 
lymphatic glands its nature may be inferred by determining the pres- 
ence of primary carcinoma in other organs of the body, or by the con- 
dition of the lymphatic glands in other parts. If they are the seat of 
malignant disease this usually can be recognized. In the case of Hodg- 
kin's disease the examination of the blood may be of service in the 
diagnosis. Cancer of the liver must be excluded by its symptoms — 
enlargement with jaundice, with moderate fever, rapid emaciation, and 
short duration of the disease. 

Diseases of the Spleen. 

Palpation and Percussion of the Spleen. The spleen lies in 
the left upper quadrant beneath and in contact above with the dia- 
phragm and below with the tail of the pancreas, cardiac end of the 
stomach, and supra-renal capsule. It extends transversely between the 
upper border of the ninth rib and the lower border of the eleventh 
rib, and from the middle axillary line posteriorly toward the spine. 

An enlarged spleen usually retains the shape of the normal organ. 
It is accessible to palpation in proportion to the degree of the enlarge- 
ment of the organ, and of relaxation of the abdominal walls. When 
moderately enlarged the smooth, blunt, rounded anterior surface and 
sharp edge of the spleen can be felt at the margin of the ribs in deep 
inspiration ; and when the enlargement is great, as in leukcemia, the 
organ can be grasped with both hands, and its hilus clearly mapped 
out. The same thing can be done in the rare instances of floating 



620 



SPECIAL DIAGNOSIS. 



spleen, but here a knee-chest position will favor successful palpation. 
In splenic leukaemia the spleen may be larger after a meal, yield a 
creaking fremitus on palpation, a murmur on auscultation, and may 
even pulsate. The spleen may also lessen in size following diarrhoea 
or free hemorrhage. As it lies entirely behind the ribs when of normal 
size, of course it does not admit of palpation. 

Percussion. Being a solid body it gives a dull sound on percus- 
sion, contrasting with pulmonary resonance above, intestinal tympany 
below, and stomach tympany anteriorly. Posteriorly and below its 
dulness merges into that of the lumbar region and kidney. The upper 
posterior portion is hidden behind the diaphragm and overlapping 
lung, and hence is not accessible to percussion. Practically, therefore, 
the normal splenic dulness extends between the ninth and eleventh 
ribs, in the middle axillary and posterior axillary lines, the spleen 
being there in contact with the ribs. 

In percussing the spleen the patient should lie on his right side. 
Beginning from above downward we percuss gently until pulmonary 
resonance is succeeded by dulness; and then anteriorly, proceeding 
toward the axilla, until stomach tympany yields to dulness. In the 
same way, percussing from below upward, the line is reached where 
intestinal tympany gives way to dulness. 

The spleen may be compressed by a stomach or colon distended with 
gas, aud its dulness may appear increased through distention of the 
stomach and colon with solid matter, or by a left pleural effusion, or 
left basal pneumonia. The spleen may also be pressed up by ascites 
or by a large abdominal tumor, so that its normal dulness is much 
lessened. 

If the ligament which holds it in place become relaxed, the spleen 
may become floating. According to Stintzing a floating spleen is in- 
creased in density, is generally enlarged, and is recognized by its form 
(notch, etc.), by being movable to and fro, and by the absence of splenic 
dulness in its normal position and its reappearance when the spleen is 
replaced. 

Enlargement of the spleen may be acute or chronic. Acute enlarge- 
ment occurs in certain infectious diseases, particularly typhoid fever, 
typhus, smallpox, relapsing fever, scarlet fever, diphtheria, epidemic 
cerebro-spinal meningitis, the malarial fevers and meningitis, in diseases 
with blood poisoning, as septicaemia, puerperal fever, and erysipelas. 

A rare cause of enlargement is acute splenitis. Generally it is the 
result of emboli lodged in it aud starting from an endocarditis. The 
area of splenic dulness is increased rapidly, and there are local pain 
and tenderness on pressure, increased by coughing and deep inspira- 
tion ; other symptoms are fever, nausea and vomiting, and occasion- 
ally delirium. If, as frequently happens in splenitis, emboli lodge in 
the kidneys also, the urine will be albuminous and bloody. If suppu- 
ration ensue the fever becomes hectic and the spleen continues to 
increase in size. Splenic abscess may, however, remain latent until 
rupture occurs. 

Enlargement of the spleen can be distinguished from enlargement 
of the left kidney by the greater movability of the spleen. 1. The 



LIVER, SPLEEN, AND PANCREAS. 



621 



spleen does not extend as far back toward the spine as the kidney, 
so that the fingers can be thrust behind its posterior border, and 
if the other hand grasp the anterior edge the organ can be moved 
backward and forward. Splenic d illness extends to the ninth rib or 
higher. Kidney duluess has no thoracic area, but reaches to the spine 
(lumbar). 2. Again, the spleen is movable with respiration, while the 
kidney is not. 3. The spleen falls farther toward the median line, 
when the patient is in the knee-chest position, than the kidney does. 
4. An enlarged kidney has the colon in front of it, and hence its dul- 
ness is obscured by the tympany of the bowel. 5. The shape of an 
enlarged kidney is more globular than that of the spleen. The ante- 
rior surface of the latter is smooth and rounded, but at its junction 
with the flat posterior surface there is a sharp edge. 6. Pain in renal 
diseases often shoots down the ureters and into the testicles. In dis- 
eases of the spleen the pain is generally localized to the splenic region, 
and may shoot into the left shoulder. 7. Result of examination of the 
urine will often make clear that the disease is renal, or, by its negative 
result, will point to the spleen as the cause of the tumor. 

Chronic enlargement of the spleen occurs as hypertrophy and as the 
result of amyloid disease, leukaemia and pseudo-leukaemia, chronic 
malarial poisoning (ague-cake), syphilis, hydatid tumor, and cancer. 
Enlargement is greatest in leukaemia and in ague-cake. The spleen in 
well-marked cases of these affections may reach to the umbilicus and 
even beyond, filling up the hypogastrium and extending to the right 
iliac region, measuring thirteeu or fourteen inches in length and half as 
much in breadth, and proportionately increased in thickness. 

Diagnosis of Enlargement of the Spleen. The diagnosis 
of splenic leukcemia rests principally upon the blood condition, particu- 
larly upon the existence of a marked increase of white blood-cells. 
Red cells are decreased, and altered forms are present. In addition to 
characteristic blood changes there is a great disposition to hemorrhages ; 
dropsies and priapism are common ; and in the late stages fever, diar- 
rhoea, great weakness, and grave complications, such as pneumonia, 
occur. 

Hemorrhage in splenic leukaemia occurs from the nose, bowel, 
stomach, gums, or kidney. It may also be subcutaneous, intermuscular, 
cerebral, or retinal. 

Regarding the diagnosis of splenic hypertrophy (ague-cake) in chronic 
malarial affections, Osier says : " The history of malarial cachexia, the 
absence of lymphatic enlargement, and the blood condition, will usually 
be sufficient for the purposes of a diagnosis. Great increase in the 
white blood -corpuscles is not often seen in the chronic splenic tumor of 
malaria; indeed, they may be much diminished in number. Toward 
the end in very chronic cases the clinical picture may be very similar ; 
the large abdomen, possibly ascites, dropsy of the feet, and irregular 
fever may resemble closely splenic leukaemia, and the absence of an 
increase in the colorless corpuscles may be the only marked difference." 

Amyloid spleen with enlargement of the organ occurs in conditions 
attended by prolonged suppuration, especially when the bones are 
involved, and in chronic phthisis and syphilis. The spleen is en- 



622 



SPECIAL DIAGNOSIS. 



larged, hard, and painless. The enlargement is rarely great enough to 
produce distress ou that account, and it is so commonly associated with 
a similar condition of the liver and kidneys, if not of other organs, 
that any constitutional symptoms produced by the spleen are apt to be 
masked by those produced by other organs. 

Hydatid tumor of the spleen rarely causes any symptoms except when 
it becomes very large; then it may give rise to discomfort and a 
dragging pain in the left hypochondrium. But hydatid tumors of the 
spleen are only exceptionally very large ; when large enough to admit 
of palpation, and when the tumor is situated anteriorly or projects 
from the lower border or from beneath the organ, the detection of fluctua- 
tion, the withdrawal of the characteristic cystic fluid by aspiration, and 
possibly the hydatid fremitus, will establish the diagnosis, when taken 
in connection with the gradual development of the tumor and exposure 
to possible infection. In the absence of physical signs of a cyst, the 
diagnosis can only be suspected from the habits of the patient or his 
place of residence. Suppuration of the sac may be brought about by 
injury, or rupture into the adjacent cavities with grave, if not fatal 
results. 

Inherited, syphilis and chronic syphilis of considerable duration are 
accompanied by enlargement of the spleen. They cause a chronic 
interstitial inflammation. The enlargement is not very great, and does 
not possess characteristic features. 

Malignant tumors of the spleen are very rarely primary. The 
diagnosis must be made by noting malignant disease elsewhere, the very 
rapid enlargement of the spleen, with possibly nodules scattered over 
its surface, and the presence of cachexia and the usual constitutional 
signs of a malignant disease. 

In young children enlargement of the spleen is not uncommon. It 
is found associated most frequently with rickets, syphilis, and malarial 
poisoning, and has been attributed to each of these diseases as a cause. 
In the London Lancet, April 30, 1892, Dr. J. W. Carr analyzes thirty 
cases, and comes to the conclusion that the enlargement of the spleen is 
due to splenic anaemia, the essential cause being unknown. Rickets, 
syphilis and ague are found as passing causes only, since the disease is 
found in some cases where these causes can be excluded. According to 
this author, the disease is extremely rare in children older than two and 
one-half years. 



Diseases of the Pancreas. 



The function of the pancreas, or at least isolation of its functional 
activity from the functions of organs physiologically associated with 
it, is surrounded by so much obscurity that diseases of the pancreas 
are attended by the same obscurity. As the pancreatic secretion aids 
in intestinal digestion, particularly in emulsifying fats, symptoms due 
to disturbance of this function are looked for, and it is true in a measure 
in all cases of pancreatic disease that there is some intestinal indigestion. 
For the purpose of determining whether the function of digestion of fats 
has been modified, the patient with suspected pancreatic disease is given 



LIVER, SPLEEN, AND PANCREAS. 



623 



fats in some form and the stools watched. If fat is passed in the stool 
in the amount taken by the mouth, without being broken up, or emulsi- 
fied, it is held as proof that disease of the pancreas is present. While 
fatty stools may be indicative of pancreatic disease, the absence of fat in 
the stools in patients who are fed upon it cannot be used as a means of 
the exclusion of disease of this organ, for notwithstanding its absence in 
a large number of instances in which the experiment was tried, the 
pancreas was found to be the seat of exteusive disease. Sugar has been 
observed in the urine in many cases in which the pancreas was the seat 
of the disease. In fact, glycosuria has been attributed to pancreatic 
disease in cases of grave diabetes. This symptom, however, is not 
constant in pancreatic lesions. 

The three classes of symptoms just mentioned are, therefore, not 
diagnostic of pancreatic disease, but afford presumptive evidence of its 
presence. Most striking symptoms of disease of the pancreas, apart 
from that which is due to a morbid process, as suppuration or cancer, 
are the symptoms due to a tumor pressing upon surrounding structures. 
It may press upon the gall -duct, causing jaundice. It is one of the most 
frequent causes of obstructive jaundice. Finally, some diseases of the 
pancreas may cause a tumor situated in the epigastric region which may 
resemble an aneurism, a tumor of the pylorus, or of the transverse colon. 
Tumors of the pancreas are usually due to cancer. This is usually of the 
scirrhus variety, and generally primary. The enlargement cannot be dis- 
tinctly made out unless the patient emaciates very much. When it has 
advanced considerably it may simulate aneurism, but is distinguished 
by the difference in the character of pulsation. In aneurism the pul- 
sation is distensile, in disease of the pancreas it is an up-and-down 
movement. The hand is lifted with each pulsation of the aorta. Tumor 
of the pylorus is excluded largely because of the more superficial posi- 
tion of the mass, because of its association with pyloric obstruction, 
and with less frequent jaundice than in disease of the pancreas. A 
pyloric tumor is more movable and may change position after the 
stomach is inflated by gas or distended by fluid. Examination with the 
patient on the hands and knees may aid in the distinction between the 
two. In a tumor of the transverse colon its nearness to the surface and 
movability, its association with more or less constipation, with occur- 
rence of intestinal hemorrhage, are of diagnostic significance. 

The general symptoms of the cancerous cachexia ; the occurrence of 
intestinal indigestion, or of fatty stools ; the gradual onset of jaundice ; 
epigastric pain, which is complained of as deep-seated ; an immovable 
tumor, with glycosuria, make a symptom-group very characteristic of 
cancer of the pancreas. 

Hemorrhage. We owe to F. W. Draper and Prince our knowl- 
edge of hemorrhage into the pancreas. Since their labors the affection 
has been frequently recognized. The attack comes on suddenly in the 
midst of perfect health, and usually terminates life in a short period. 
Nothing in the occupation or conduct of the patient at the time favors 
the development of the hemorrhage. He is seized with severe pain, 
which is localized in the upper part of the abdomen. It increases in 
severity, is most intense in character, and may intermit like colic. 



624 



SPECIAL DIAGNOSIS. 



Nausea and vomiting take place almost at the same time. The vomit- 
ing becomes obstinate. Extreme depression rapidly sets in and the 
patient becomes anxious and restless. Collapse ensues in a short time. 
The extremities become cold and the forehead is covered with sweat. 
The pulse increases in frequency and rapidly diminishes in strength. 
It soon becomes imperceptible. The pain and vomiting call attention to 
the upper abdomen. It is tender on pressure ; this may extend through- 
out the entire upper half of the abdomen. Tympanites may develop. 
There is constipation in many of the cases. The temperature remains 
normal, or becomes subnormal. The pain, the vomiting, the anxious 
and restless state continue without relief. 

From the above group of symptoms it can readily be seen that the 
diagnosis is obscure. It can be taken for perforation of the stomach 
by ulcer, although the vomiting may not be so persistent and frequent. 
Intestinal obstruction in the upper portion of the tract presents 
allied symptoms. The hemorrhagic symptoms, however, are more 
pronounced in pancreatic hemorrhage. Pallor of the face is sure to 
ensue. The vomiting is not fsecal in character. Constipation can 
be relieved. It is, however, difficult and in many cases it may be im- 
possible to establish a diagnosis. The rapidity of development of the 
symptoms is of importance. The pain and collapse may be due to 
rupture of an aneurism of the aorta. 

Acute Hemorrhagic Pancreatitis. To another Boston professor 
we owe our knowledge of this disease; at least to Fitz we are indebted 
for collating the facts from the literature to which are added the re- 
sults of his own valuable observations, by which we can recognize this 
affection during life. A patient with hemorrhagic pancreatitis has been 
previously subject to attacks of indigestion, attended by pain and 
vomiting; many use alcohol to excess. The attack develops suddenly, 
resembling somewhat hemorrhage of the pancreas. There is violent 
pain which is at first complained of in the upper abdomen, although it 
is sometimes general. Nausea and vomiting are present in all the 
cases; constipation in most of them. The abdomen is frequently the 
seat of tympanitic distention. Collapse symptoms supervene, although 
fever may occur. The cases terminate before the fourth day, sometimes 
earlier. The pain and collapse are probably due to swelling which in- 
volves the coeliac plexus. 

The symptoms resemble intestinal obstruction. In several instances 
laparotomy has been performed for the relief of supposed obstruction. 
The intense pain in the epigastrium, the violent vomiting and distention 
of the upper abdomen, without a possible cause for obstruction, are 
favorable to acute pancreatitis. The difficulty of diagnosis, however, is 
so great that resort to laparotomy is justifiable in order to determine 
exactly the nature of the condition. 

Suppurative Pancreatitis. Fitz has found that this affection 
occurs in adults under forty, more frequently in males. Symptoms con- 
tinue during several weeks, and may persist for a year. Pain in the epi- 
gastrium is complained of, associated with irregular vomiting, the latter 
persisting in spite of care as to feeding. Fever is irregular in type, and 
exhaustion ensues. In the case under my observation, obstruction of the 



LIVER, SPLEEN, AND PANCREAS. 



625 



portal vein took place, with ascites. The latter was large, and recurred 
rapidly after tapping. In this patient the pain and gastric disturbance 
were absent. There was no fever. Emaciation, constipation, and 
a tumor above the umbilicus were present; the emaciation was extreme. 
The tumor was ill-defined, painless, apparently superficial. Many other 
symptoms of pancreatic disease pointed out by Roberts were present. 
Apathy and despondency were marked ; bronzing of the face was also 
present. The patient was a middle-aged man, aged forty-two, addicted 
to the use of alcohol. He was thought to have cirrhosis of the liver. 
As happened iu my case, the pus may accumulate in the duodeno- 
jejunal fossa and fill up the cavity of the lesser peritoneum, with more 
pronounced symptoms of tumor than occur in similar fluid accumula- 
tions in the above-mentioned cavity. 

Gangrenous Pancreatitis. This may follow later upon hemor- 
rhages into the pancreas. The symptoms are extremely obscure during 
life. Symptoms of collapse may occur, following pain, which is of 
longer duration than in the acute form, or vomiting, which is not so 
persistent. In my case a patient upward of sixty years suffering from 
dyspepsia vomited blood during the course of an illness which was 
characterized by loss of flesh and weakness. The anaemia became very 
profound after the gastric hemorrhage, and exhaustion was extreme. 
There was no marked tumor, but resistance in the region below the 
xiphoid. There were dulness and tubular breathing at the base of the 
left luug. Fever was absent. Death ensued from exhaustion. A small, 
flat carcinoma was found in the pyloric end of the stomach, but there 
was no perforation. Gangrenous paucreatitis, with signs of an ante- 
mortem hemorrhage, was found. The accumulation took place behind 
the stomach and colon, but in front of the kidney; its outer wall was 
bounded by the spleen. It was circumscribed above by the diaphragm. 
Pleuritis and small pulmonary abscesses at the base of the left lung 
were found. 

In some instances the pancreas has sloughed into the bowel, and in 
two such cases recovery took place after its discharge from the rectum. 

Chronic 'pancreatitis is not recognized during life, although its 
possible presence must be considered in all cases of diabetes. 

Cyst of the Pancreas. Cysts of the pancreas follow impaction of 
calculi in the pancreatic duct; sometimes the biliary calculi obstruct the 
orifice. The symptoms are those of tumor in the upper abdomen, which 
occupies the median position, or is chiefly on the left side in the upper 
quadrant. It may fill the abdominal cavity and simulate ovarian 
tumor. It usually develops slowly, but cases of rapid onset have 
been described. Fatty diarrhoea is not present. There is a sense of 
weight and fulness in the epigastrium. The cysts are not really true 
cysts, but accumulations of pancreatic fluid in the lesser peritoneal 
cavity. The signs are those of a tumor to the left of the median 
line, encroaching upon the left lobe of the liver above, and extending 
almost to the transverse umbilical line. It is smooth, and may 
fluctuate; it is not hard and lobulated. On account of its presence 
the diaphragm may be arched so that the heart is dislocated to the 
left and upward ; the apex is found in the third interspace. It also 

40 



626 



SPECIAL DIAGNOSIS. 



causes increased dullness behind on the left side, the upper border 
approaching the angle of the scapula. Exploratory puncture in either 
instance determines the nature of the fluid and may positively de- 
termine the diagnosis. (See Examination of Cystic Fluids, page 170.) 

Senn has pointed out that in cysts of the pancreas the complexion is 
peculiar ; it is described as an unhealthy yellow, dirty, or earthy hue. 
This writer also considers that in the diagnosis of pancreatic cyst the 
history of the case, the location of the tumor, and its relation to other 
organs are to be considered. The disease occurs in adults, aud usually 
follows traumatism. A blow in the epigastrium is a prominent excit- 
ing cause. In some instances it occurs after an attack of so-called 
biliary colic or colicky pains in the upper abdomen, with vomiting, but 
without jaundice, characteristic of calculus in the pancreatic ducts. The 
growth of the tumor is unusually rapid — a point in favor of its pan- 
creatic origin. It may attain an enormous size, as previously mentioned. 

In contrast to cancer, pain is absent. Fatty stools are absent. 
Previous gastro-intestinal derangement maybe ascertained upon inquiry. 
Diabetes, in this as well as other affections of the pancreas, may be 
present. The cyst is always found at first in the region occupied by 
the pancreas, depending somewhat upon the portion of the pancreas 
from which it originated. It may be below the right lobe of the 
liver, below the xiphoid, or in the left upper quadrant. In the large 
majority of cases it occupies the last situation. It displaces the 
stomach forward and to the right, the transverse colon downward, the 
diaphragm and the contents of the chest upw r ard. The cyst may be 
movable in respiration. 

Diagnosis. It must be distinguished from cancer of the pancreas 
or adjacent organs, aneurism, hydatid cyst of the liver, the spleen, or 
the peritoneum, affections of the retro-peritoneal glands, hydronephrosis, 
cystic disease of the supra-renal capsule, circumscribed peritonitis with 
exudation, ascites, cystic disease of the ovary. Pain is an important 
symptom of the disease of the pancreas in its more acute manifestations ; 
it must be distinguished from the pain of intestinal obstruction and 
the pain of perforative peritonitis. The pain is always localized to 
the region below the xiphoid, or if general is confined to the upper half 
of the abdomen. It exactly simulates the pain of the affection just 
described. This is more pronounced because of the association of 
vomiting and collapse in this class of cases. Pain that is not so intense, 
of a colicky nature, attended by a diarrhoea, or constipation, in some 
instances with intestinal hemorrhage, may be due to calculous disease 
of the pancreas. Frequently this form of pain can be recognized if 
other symptoms of pancreatic disease, such as glycosuria, steatorrhoea, 
and intestinal indigestion are present. 



CHAPTER VII. 



DISEASES OF THE KIDNEYS. 

The kidneys are affected by disease through several sources. First, 
the great vascular supply is subject to the alteration which takes place 
in any large arterial area either from direct hyperemia, through the 
influence of the vasomotor nerves (see Hyperemia), or through the ceutral 
organ of the circulation, whereby passive hyperemia or congestion 
occurs. Second, by means of the bloodvessels, thrombosis and embolism 
occur, particularly the latter, causing renal infarction. Third, infectious 
material is carried to the kidney, and in passing through the structure 
gives rise to the inflammations we see in infectious disease, either of an 
infective or simply of an irritative character. Fourth, through the 
means of the bloodvessels also, and by virtue of its function, the renal 
structure is particularly liable to irritant inflammation, for through 
it pass poisons that are ingested; and the products of metamorphosis 
which, if modified in character or increased in amount, excite irritation 
and lead to inflammatory changes. 

But the kidney is open to attack from sources lower down in the urinary 
tract. Through the bladder and ureter infection may extend upward, 
causing the consecutive inflammatory processes, which are often seen 
after disease of the urethra, bladder, or ureter. It is obvious that, if 
changes in the urine are found, one of these three causal conditions may 
be present. The kidney is at the apex of a system of tubes or channels. 
Any alteration of them, whether mechanical or functional, has a secondary 
effect upon the kidney. Obstructions of the ureter or obstruction in 
the conduits beyond lead to consecutive hypertrophy, inflammation, 
and atrophy. (See Morbid Processes.) 

The morbid processes which may take place in the kidney are such 
as are common to all organs — congestion, degeneration, inflammation, 
and morbid growth. The symptoms that attend the morbid processes 
are such, as accompany similar processes elsewhere. The general 
symptoms of the morbid processes are not pronounced except in the case 
of intense inflammation with suppuration, or of morbid growths, as 
carcinoma, because of the small size of the kidney. We have general 
symptoms, on account of the morbid process, that may point to sup- 
puration, or general symptoms due to the cancerous cachexia. Other- 
wise, general symptoms in renal disease are of small moment, except, as 
is usually the case, where there is interference with the function of the 
kidney. The local symptoms are only due to the morbid process, as 
pain in carcinoma. 

The symptoms of renal disease are the symptoms of the morbid 
process and the symptoms due to functional or anatomical alteration of 
the kidney. But the structure is so closely interwoven with the function 
that morbid changes in one imply morbid changes in the other. As the 



628 



SPECIAL DIAGNOSIS. 



anatomical alterations are usually beyond the pale of investigation, 
again, we find functional symptoms alone are appreciated. Hence in 
each morbid process we look for changes in the urine, which is the 
product of renal function, and for symptoms resulting from abeyance or 
cessation of the function. Rarely we have enlargements due to tumor, 
as cancer or abscess, or to obstruction of the channels causing hydro- 
nephrosis, or to parasitic disease. 

The urine is not alone an index of the condition of the kidneys. It 
varies, within the bounds of health, in color, quantity, and quality. 
Food, exercise, and other conditions modify the secretion. It can 
readily be seen, therefore, that any general disease and many local dis- 
eases cause alterations in the character of the urine. Any abnormal 
urine, therefore, is symptomatic of renal disease or of disease beyond 
the point at which the urine passes out of the body. Usually abnormal 
changes in the urine due to the general condition do not give rise to 
local renal symptoms or to abnormal renal function. The exception is 
seen when an excess of uric acid and urates and of oxalates is passed. 
They may give rise to local pain and may set up sufficient irritation to 
cause nephritis. 

A. The general phenomena of the morbid processes are fever and 
emaciation. Fever occurs in acute nephritis, perinephric abscess, 
suppurative and tuberculous nephritis, pyelitis, and with twists of the 
ureter in floating kidney. Emaciation occurs in chronic, suppurative, 
and tuberculous nephritis and carcinoma. The local phenomena of 
morbid processes are pain and tumor. 

B. The symptoms due to alteration of function are : 1. Urozmia. 2. 
Cardio-vascular symptoms. 3. Anaemia. 4. Dropsy. 5. Changes in 
the character of the urine. 6. Changes in the frequency and character 
of the micturition. The symptoms of renal disease are, therefore, both 
subjective and objective. 

Classification. The best classification of the diseases of the 
kidneys is that based upon the propositions of Delafield, who, in a 
paper entitled " On the Diseases of the Kidneys Popularly Called 
1 Bright's Disease,' m submitted a classification dependent upon the nature 
of the morbid process. The morbid processes included congestions, 
degeneration, and inflammations of the renal structure. In addition to 
these affections we must also include in the nosology of renal disease 
tumors (cancer, abscess, and hydronephrosis) and anomalies of growth 
or position (floating kidney, horseshoe kidney), affections due to invasion 
of the kidney by parasites, and affections due to obstruction of the tubes 
through which the offices of the kidney are carried on (renal calculus, 
hydro- and pyonephrosis). 

The Data Obtained by Inquiry. The Subjective Symptoms. 

The subjective symptoms are due to morbid processes within the 
kidney or to alterations of its function. The class of nervous symp- 
toms which belong to uraemia are subjective in character, as are also the 
symptoms of movable kidney. 



1 Trans. Arner. Physicians, vol. vi., 1891, p. 124. 



DISEASES OF THE KIDNEYS. 



629 



Pain. 1 . Pain in the kidneys is referred to the loins. It is complained 
of as a dull aching, sometimes increased by movement, often attended 
by a sense of weight or pressure. This character of pain extends over 
the entire lumbar region and is due to disease of both kidneys, as in 
acute nephritis. 2. We have, further, pain referred to one kidney. The 
pain may be seated in the region of the kidney behind, opposite the 
two lower dorsal and two upper lumbar vertebral spines; or is com- 
plained of as deep-seated, in the abdomen to the right or left of the 
spinal column below the level of the umbilicus. Pain on one side of 
the back is not generally mistaken for pain due to other causes. It may 
arise from myalgia of one side, or be due to disease of the vertebrae. 
If myalgic it may be associated with pain in other muscles and 
follow exposure to cold. Neuralgia of the kidney no doubt occurs. It 
may be due to malaria, lead poisoning, gout, or anaemia. It partakes 
of the characters of neuralgia elsewhere. 

Pain in the situations just mentioned is usually unilateral, and may 
be constant or paroxysmal. Constant pain is usually due to organic 
disease of the kidney, as carcinoma, or tuberculosis. It may, however, 
be due to the impaction of a calculus in the pelvis of the kidney. 
Paroxysmal and lancinating pain, the paroxysms recurring at long 
intervals, is due to renal calculus usually, or the presence of a foreign 
substance, as blood, in the pelvis of the kidney. The pain is not only 
seated in the regions just indicated, but extends along the ureter, so 
that it extends from the loin to the front of the abdomen. It may 
persist for some time, at a point on either side of the umbilicus above 
or below it, or at a point on the surface of the abdomen opposite the 
brim of the pelvis. From thence the pain extends into the bladder 
either above the pubis (the hypogastric region), or into the testicle, or 
down the inside of the thigh. It may be in the loin and at the end 
of the penis at the same time, or lancinate along the whole urinary tract. 
In rare cases the pain is in the kidney of the healthy side. The pain of 
renal colic is always associated with frequency of micturition with or 
without pain during the passage of the urine. The character of the 
urine often points to the nature of the pain. The urine is usually 
bloody, and at first scanty ; when the obstruction is removed it becomes 
copious. Renal pain or colic located in front of the abdomen must not 
be confounded with the pain of colic, either hepatic or intestinal. The 
pain is usually lower than in hepatic colic, extends along the course of 
the ureter, and is attended by symptoms referable to the urinary system 
and not the hepatic. 

In tumors the pain may follow the course of the sciatic nerve, 
simulating sciatica. In pyelitis and hydronephrosis the pain is of a 
tearing character. The pain is variable in floating kidney. 

Neukalgia. Neuralgia is a symptom of common occurrence in the 
course of B right's disease. It may be due to anaemia, or be of uraemic 
origin. The occipital, supra-orbital, or trifacial nerve, or other nerves, 
may be affected. Anginoid seizures attended by pain are of frequent 
occurrence. 

Frequency of Micturition. There are four causes of frequent 
micturition : (1) disease of the kidneys, the ureters, or the bladder, on 
account of irritability of the genito-urinary tract ; (2) diseases in which 



630 



SPECIAL DIAGNOSIS. 



the amount of the urine is increased, demanding very frequent efforts 
to relieve the distention, as in diabetes ; (3) diseases in which the 
urine is more concentrated, and hence causes more pronounced irritation, 
as in fevers, gout, or acute nephritis; (4) a reflex or pure neurosis. 

Increased frequency of micturition on account of disease of the 
kidneys occurs in almost all organic affections of the genito-urinary 
system. It is seen in all forms of congestion and inflammation of the 
kidneys. In chronic nephritis it may not be noticed save that the 
patient is called upon to pass urine at night, arousing from sleep for 
this purpose. In some forms of nephritis the increased frequency may 
be due to increase in the amount of urine as well as increased sensitive- 
ness of the orgaus. In the organic diseases it always occurs. The 
disease is not limited, however, to the kidneys. Disease of the ureter 
and disease of the bladder are also associated with this troublesome 
symptom. In its most aggravated and characteristic form it occurs in 
renal calculus, or when any foreign substance is located in the ureter or 
bladder. The frequency amounts to six, eight, or even a dozen times 
in an hour. It is often associated with tenesmus, the patient having a 
constant desire to urinate, at the same time passing but small amounts. 
This form of tenesmus is more frequent when the bladder or urethra is 
the seat of disease, and in renal calculus. 

The Data Obtained by Observation. The Objective Symptoms. 

The objective symptoms of diseases of the kidney are : (1) determined 
by physical examination of the organ ; (2) derived by an examination ot 
the urine; (3) due to impairment of the function of the kidney. Many 
of the latter symptoms are also subjective. 

Physical Examination. Palpation and Percussion. The kid- 
neys are situated in the right and left lumbar regions respectively, the 
left being a little higher than the right. They extend from the eleventh 
rib, or twelfth thoracic vertebra, to the third dorsal vertebra. The left 
kidney is in contact above with the spleen, and the right with the liver. 
The kidneys are enveloped in fat, more or less abundant ; their distance 
from the auterior surface of the abdomen renders them inaccessible by 
palpation or percussion from that direction, and the thick dorsal and 
lumbar tissues, coupled with the relation of the kidneys with the organs, 
spleen and liver, which give a dull note on percussion, makes it difficult 
to outline the kidneys from behind. The best results are obtained by 
having the patient lie face downward, placing a cushion under the belly 
so as to make the lumbar regions a little more prominent. Strong per- 
cussion is required, and an artificial plessor and plexi meter are to be 
preferred. Percussion should be conducted with a view to marking the 
angle which the liver dulness and splenic dulness make with that ot 
the kidney on the right and left sides respectively. The kidneys extend 
below the lower lines of liver and splenic dulness, and laterally for a 
width not greater than four inches. The difficulties in the way of out- 
lining the kidneys by percussion are greatly increased in persons with 
much flesh, or when the abdominal walls are waterlogged, as they be- 
come in ascites, and practically it is impossible under such circumstances 



DISEASES OF THE KIDNEYS. 



631 



to be sure of the boundaries of the kidneys. The colon must be empty 
to make the examination trustworthy. 

Enlargements of the kidney are detected usually, first, by percussion, 
the width of the kidney being increased, and the percussion dulness 
exteuding, therefore, farther to the right or left, according as the right 
or left kidney is affected. As the causes which produce enlargements of 
the kidney which are sufficiently great to be detected by percussion do 
not, with rare exceptions, involve both kidneys at the same time, com- 
parison of the two sides is of great value in the diagnosis. 

Palpation of the kidney becomes possible when it is either enlarged 
or displaced. In the case of an enlarged kidney, the patient should lie 
upon his back or be turned slightly to the opposite side; one hand is 
placed beneath the kidney and upward pressure made while the other is 
pressed firmly and steadily from above or laterally toward the kidney. 
In this manner the kidney can be grasped between the two hands, its 
size estimated, and its physical characteristics as regards hardness, 
softness, fluctuation, and mobility determined. Enlargements are also 
detected by palpation of the abdomen. The renal tumor is usually two 
to three inches to either side of the median line, a little above the 
transverse umbilical line. 

The diseases of the kidney attended by enlargement are malignant 
tumors, tuberculosis, cysts, abscess, hydro- and pyonephrosis, and peri- 
nephritic abscess. 

In abscess of the kidney there is some fulness in the loin of the 
affected side. The kidney is felt to be enlarged, and is tender and pain- 
ful. A tumor may be detected anteriorly. The diagnosis is made by a 
study of the cause (acute nephritis, pyaemia, impacted calculus in the 
ureter, erysipelas), and the detection of blood and pus in the urine, 
which is scanty ; and by the constitutional symptoms. The progress of 
the case is usually acute. If the abscess is tubercular, tubercle bacilli 
can be detected in the purulent sediment of the urine, and there will be 
other foci of tuberculosis with a corresponding clinical history. 

In malignant tumors of the kidney the surface is no longer smooth, 
and nodules may be felt. 

In pyonephrosis the tumor is tense, smooth, and globular. Fluctua- 
tion may be detected. Tenderness is usually absent, and the course is 
slow and does not affect the general health so much as abscess. The 
pus may be discharged copiously from time to time, and the tumor be 
therefore diminished in size. The urine may be nearly clear at one 
time. Pyonephrosis arises secondarily to pyelitis, and often after the 
latter has lasted some time. 

Hydronephrosis consists in a dilatation of the kidney pelvis with urine, 
which is prevented from escaping by obstruction of the ureter, either 
by the pressure of a tumor or by disease of the bladder or ureter itself. 
In time the kidney atrophies from the pressure and a large cyst forms. 
The tumor has the physical characters of pyonephrosis, but the history 
is different, and if there is any discharge it is free from pus. As in 
pyonephrosis, the tumor may become smaller, following a copious dis- 
charge — in this case of urine — or even may wholly disappear if the 
obstruction is removed. This sign is pathognomonic. 



632 



SPECIAL DIAGNOSIS. 



If obstruction continue to be absolute, the diagnosis must be made by 
the detection of a fluctuating renal tumor, the absence of fever and signs 
of suppuration, and by the result of exploratory puncture. The urine 
is usually free from chauges. 

It may be confounded with ascites if very large, but the hydro- 
nephrosis is rarely bilateral, and the fluid in it does not change its 
level upon change of position of the patient, as is the case with ascites. 
The history of the two conditions will be different. 

An ovarian cyst can usually be traced into the pelvis, does not carry 
the colon in front of it, but is dull and even superficial on percussion, 
and leaves the loins resonant. 

An echinococcus of the kidney presents the usual physical signs of 
such cysts. A fremitus may be detected or small cysts be found in the 
urine. 

In the diagnosis of renal tumors in general it should be borne in 
mind that they are very rarely, almost never, movable with respiration. 
Unless too large they preserve their reniform shape, and press in front 
of them the ascending or descending colon, whereas ovarian tumors lie 
behind it. The position of the colon should therefore always be ascer- 
tained, and to this end it may be necessary to inflate it with air. 

Perinephritis arises usually from extension of inflammation and 
suppuration from the kidney, but may be the result of strain, exposure 
to cold, or injury. Perinephritis may also be pysemic, and occurs after 
infectious fevers. Gibney has reported twenty-eight cases occurring in 
children. 

The swelling of a perinephritic abscess appears in the lumbar region 
of the side affected. It is rounded in form and doughy (Da Costa). 
Like other kidney tumors it is not affected by respiration. The usual 
signs of confined suppuration exist, and pulmonary or pleural complica- 
tions may occur. As the abscess progresses the local signs of suppura- 
tion become more marked, the skin reddens, and pus may be discharged 
externally. 

The most marked subjective symptom is pain, which may amount to 
agony, and is paroxysmal ; soreness from restricted motion of the psoas 
muscle is apt to be complained of. 

A tumor was present in the loins in sixty-five out of seventy-one 
cases analyzed by Fenwick, but generally did not manifest itself until 
the inflammation had made considerable progress. There is dulness on 
percussion even in the early stage, and later fluctuation. The general 
symptoms are vomiting, constipation, fever, and sometimes rigors. It 
is more commou in males than in females (sixty-one males to thirty- 
nine females in Fenwick's cases) ; and is most apt to occur in persons 
who have suffered from renal calculi, pyelitis, or scrofulous kidney, 
often operations in the bladder and urethra, or when the patient has been 
subjected to injuries or strains of the loins, or to exposure to cold or 
wet when in a heated condition (Fenwick). 

Floating kidney is best detected by palpation. It is recognized by 
its bean shape, its movability, the detection of the hilus and perhaps of 
the pulsation of vessels in it, and by the fact that it can be replaced. 
Palpation causes a sickening feeling, analogous to that experienced when 



DISEASES OF THE KIDNEYS. 



633 



a testicle is compressed, but less in degree. A knee-chest position 
facilitates palpation. The value of relative percussion over the two 
kidney regions as a means of showing the absence of the kidney is much 
overrated. But the percussion will of course demonstrate that a body 
supposed from palpation to be the kidney is a solid organ. 

The patient sutlers from a feeling of lack of support in that region, 
which induces inaptitude and perhaps inability to work. The urine 
itself does not usually present any abnormalities. 

Malignant tumors of the kidney, when primary, occur in a large 
number of cases in children. Twenty-five out of sixty-seven cases col- 
lected by Dr. William Roberts occurred in children under ten years of 
age. The most important symptoms are pain, hematuria, and tumor. 
The latter may grow with great rapidity and attain enormous size, fill- 
ing the abdominal cavity and giving rise to pressure symptoms in sur- 
rounding organs. The growth occurs preferably anteriorly and downward 
toward the pubis, because there is less resistance in these directions. On 
palpation of the abdomen the tumor may appear smooth or irregular 
and undulated. As rapidly growing cancers are soft, the tumor fre- 
quently exhibits a certain degree of elasticity, which may be mistaken 
for fluctuation. It is immovable either by the hands or with respira- 
tion. 

On percussion the resistance is increased and the note is dull, except 
in front, where the colon, which has been pushed forward, gives a tym- 
panitic note. If the colon should be flattened out between the tumor 
and the abdominal wall it may be felt as a band stretching across the 
tumor, with dulness on percussion. In such a case inflation of the colon 
with air will be of great assistance in the diagnosis. Rare physical 
signs are pulsation and a blowing murmur. 

Examination of the Urine. 

1. Inspection. The urine in health is a clear yellow or amber- 
colored fluid, having a specific gravity of about 1020, and generally 
acid in reactiou. It contains normally about forty-five parts in the 
thousand of solid matter, the principal part of which is urea — twenty- 
one and a half parts. The other solids are uric acid and its salts ; cer- 
tain extractives — creatin, creatinin, ammonia, hippuric acid, xanthin, 
hypoxanthin, sarcin, pigment, etc. ; and chlorides, phosphates, sul- 
phates, with their bases, soda, potash, lime, and magnesia. 

The volume of urine passed in twenty-four hours is usually from 
forty to fifty ounces ; but it may fall to thirty ounces or rise to seventy 
without the existence of disease. Women are believed to pass from 
five to ten ounces less than men. The volume is diminished when the 
skin is acting freely, as in warm weather, and when the bowels are 
loose ; and, on the other hand, cold, nervous excitement, especially if it 
induce anxiety and fear, and constipation, all tend to increase the quan- 
tity secreted. 

Color. The color of the urine is due largely but not wholly to uro- 
bilin, which is formed from the haematin of the blood. The color 
deepens when the urine is concentrated, as it becomes after a hearty meal 



634 



SPECIAL DIAGNOSIS. 



or exercise, especially in warm weather, and becomes paler when a large 
quantity is passed. The color frequently is changed in disease. In 
fevers the urine soon after being passed is apt to become turbid from the 
precipitation of urates, and the color varies from white, especially in 
children, to yellow, brown, or pink. When the precipitate settles, the 
supernatant urine may be high-colored and clear, or slightly opaque 
from some suspended matter. 

The admixture of pus and chyle gives the urine a milky color. The 
urine may also be yellowish-white and turbid from phosphates, semen, 
sarcinse, and bacteria. 

The urine is red, reddish-brown, or "smoky" in acute nephritis, the 
color being due to blood. It is bloody in hsematuria, cancer of the 
kidneys and bladder, and in injuries of the genito-urinary apparatus. 
A very red, clear urine is met with in concentrated urines containing a 
large amount of urates. The red color of the urine may be due to 
contained haemoglobin, constituting hemoglobinuria, or to urobilin, as 
in scurvy and pernicious anaemia. This occurs as the result of the 
action of certain poisons, such as chlorate of potash ; in infectious 
diseases, such as scarlet fever, and in malarial fevers, also in a peculiar 
disease known as paroxysmal hsemoglobinuria. 

Again, a golden red discoloration of the urine is common in jaun- 
dice ; frequently the upper layers by reflected light have a greenish 
tinge. 

Finally, a red color is produced by the internal administration of 
logwood and fuchsin. 

A yellow color when opaque may be due to suspended phosphates and 
urates. Urine is also sometimes golden yellow or of a saffron color in 
jaundice, and from the effects of santonin, picric acid, and rhubarb 
taken internally. A yellow or yellowish-white turbidity may be due 
also to a mixture of pus and phosphates, and sometimes to semen, sar- 
cinee, and bacteria The urine usually becomes more or less opaque and 
yellow when it has undergone alkaline fermentation. Such a change 
occurs normally within a longer or shorter time after the urine has been 
passed. It is promoted by heat and exposure to air, and retarded by 
cold and exclusion from air. The urine whenever possible should 
be examined before this fermentation has occurred. Pathologically, in 
cases of cystitis, the urine is passed already in alkaline fermentation. 

The urine is sometimes chocolate-brown when it contains blood and 
the blood has been acted upon by the urine, producing methaemoglobin. 

Brown, greenish-brown, or black urine may result from contained bile 
salts; from indican ; from carbolic acid, creosote, and tar used inter- 
nally and externally ; from the internal use of senna, and in cases where 
there are melanotic tumors. Senator injected melanin into human beings 
and obtained in four cases only a large indicanuria. 

Urine is pale usually in proportion as it is copious in quantity. It 
is paler in those who are using milk or vegetable diet than in those who 
eat meats. Under the influence of nervous excitement, especially anxi- 
ety and the dread of an approaching ordeal, such as an examination, 
an abnormal quantity of very pale urine is secreted. 

Pathologically, pale urine is characteristic of that passed in diabetes, 
chronic Bright's disease, and polyuria. Such urine is also secreted in 



DISEASES OF THE KIDNEYS. 



635 



hysterical attacks, at the crisis of febrile diseases, and in anaemic con- 
ditions. 

The Volume of the Urine in Disease. The volume may be 
increased, diminished, or unchanged in disease. It is increased prin- 
cipally in three diseases — diabetes mellitus, diabetes insipidus, and 
in the middle period of chronic Bright's disease, especially the inter- 
stitial form. In diabetes mellitus it sometimes exceeds thirty-two 
pints. It may be increased also in hypertrophy of the left ventricle, 
which induces greater pressure in the renal arteries as well as in the 
whole arterial system, and in cystic degeneration, and in double hydro- 
nephrosis. 

The urine is diminished in acute nephritis and in the final stages of 
chronic nephritis ; sometimes, also, it is diminished in the middle period 
of chronic nephritis, but usually it is here increased. All diseases which 
directly or indirectly impair the force of the circulation lessen the 
secretion of the urine. Hence the quantity is diminished in diseases 
of the heart muscle, and in valvular diseases not fully compensated ; in 
emphysema and in chronic bronchitis. It is lessened also in cirrhosis 
of the liver. In febrile diseases the urine is scanty aud high-colored, 
and sometimes it is almost suppressed (anuria). 

The urine is sometimes suppressed in acute nephritis, such as follows 
scarlet fever, and in the final stages of all the organic affections of the 
kidneys — chronic nephritis, hydro- and pyonephrosis, etc. It may 
result (1) from the destruction of the secreting tissue of the kidney or 
interference with its nervous or vascular supply, or (2) from mechanical 
obstruction to the outflow of the urine. To the first class belong the 
cases of suppression occurring in acute and chronic nephritis, and the 
suppression from shock and collapse, whether occurring in the stage of 
collapse of yellow fever, cholera, and other grave febrile diseases, or 
from serious internal injuries. 

Such suppression sometimes follows, also, slight operations on the 
urethra (urethral fever) ; or results from the internal administration of 
drugs the excretion of which occasions violent irritation of the kidney 
— cantharides, turpentine, and even the inhalation of ether. Clinically, 
suppression not due to obstruction is distinguished from the obstructive 
form by the character of the urine, which is usually not entirely sup- 
pressed, and by the more rapid course of the disease. The urine, 
according to Roberts, is either concentrated or it contains albumin, blood, 
and casts. Death or recovery results within a day or two. In the 
obstructive form, on the other hand, the urine which escapes past the 
obstacle is pale, watery, and devoid of albumin and casts. 

Obstructive suppression is the result of the plugging of the ureter by 
a calculus when the opposite kidney is either absent or incapable of 
secreting. Or it results from the occlusion of the ureters by morbid 
growths, especially at the vesical orifices, from lateral pressure upon the 
ureters, or from some interference or malformation of the ureters or 
renal arteries. 

Acute transient obstructive suppression occurs sometimes in persons 
with enlarged prostates who have drunk too freely of alcoholic beverages 
aud perhaps have wound up a debauch by sexual intercourse. 



636 



SPECIAL DIAGNOSIS. 



The Density of the Urine. The average density of normal urine 
is about 1020. It may fall to 1015 or rise to 1025, depending upon 
the quantity of fluid and food taken, the condition of the atmosphere, 
especially as regards temperature, and upon the presence or absence of 
mental emotions. The specific gravity of the urine is tested by a urin- 
ometer graduated for degrees of density between 1000 and 1040. Only 
a reliable instrument should be used. As the density of the urine 
passed at different times of the day varies greatly, the urine for the 
whole twenty-four hours should be saved and a specimen of this tested. 

The method of taking the specific gravity is very simple. A test- 
tube or graduate having a diameter of about one and a quarter inches 
and a length of six or seven inches is filled with urine to such a point 
that the lowest part of the urinometer floats clear of the bottom of the 
tube. The instrument must also float free of the sides of the 
tube. The specific gravity should then be read off from below, that is 
to say, by holding the tube up so that the level of the fluid is a little 
above that of the eye. Most urinometers are graduated for 60°, but in 
ordinary examinations it is not necessary to have the urine exactly at 
this temperature, but it should be allowed to cool after it has been 
passed, otherwise the specific gravity will appear to be too low. 

In disease the specific gravity varies more widely than in health ; it 
may fall to 1000 or 1005 in diabetes insipidus and chronic Bright's 
disease, and rise to 1060 or even higher in diabetes mellitus. As a 
rule, to which the urine in diabetes mellitus is the principal exception, 
the color is an index of the density, pale urine being of a low density 
and high-colored urine of a high density. 

The density is increased when the urine is scanty in amount, whether 
as the result of fever, acute nephritis, large consumption of solid food, 
excercise, or free sweating. In all such cases the specific gravity rarely 
rises above 1035, and usually not above 1028 or 1030. When the 
specific gravity rises above 1035, and the urine is pale in color, the 
presence of sugar is to be suspected ; and when it rises above 1040 
sugar is almost certainly present. 

The specific gravity is lowered by drinking copiously of fluids, by 
the effect of external cold, by a diet of vegetables and milk, and in 
general by the same causes that make the urine copious. Usually, but 
not always, a urine containing a large amount of albumin is of low 
density. 

Pathologically, a low specific gravity is encountered in diabetes insipi- 
dus, in which it may fall nearly or quite to 1000 ; generally in the 
middle or quiescent period of chronic Bright's disease; in the crises of 
fevers; in obstructive suppression; in hysterical attacks, and in hydro- 
nephrosis. 

Specific Gravity as an Index of the Amount of Solids. If the last 
two figures of the specific gravity be doubled the sum will represent the 
amount of solid matter in 1000 grains of urine. This is Trapp's 
method; the estimate is only rough, but it is useful. Of course, the 
urine for twenty-four hours must be used. 

Reaction. The reaction of healthy urine is usually acid, but it may 
be neutral or slightly alkaline about two hours after a meal of mixed 



DISEASES OF THE KIDNEYS. 



637 



food. The acidity is tested with litmus paper; the blue paper is turned 
purple or red by au acid, and the red paper is turned blue by an alkali. 
Violet paper is to be preferred, as it is suitable for showing both reac- 
tions, an alkali turning it blue and an acid red. 

The acidity of the urine is increased in gout, lithiasis, acute rheu- 
matism, diabetes, chronic Bright's disease, and as the result of the 
administration of vegetable or mineral acids. 

The urine is alkaline as the result of alkaline fermentation in 
the bladder in cystitis ; from the presence of much blood or pus ; 
from prolonged immersion of the body in a cold bath ; in debilitating 
diseases and in some cases of nervous dyspepsia, and as the result of the 
internal administration of alkalies. 

Urinary Sediments. A white flocculent sediment composed of 
epithelium and mucus occurs normally in most urines after they have 
stood for some hours. 

A dense sediment varying in color from that of brown sugar to pink 
or red, consists of amorphous urates. It dissolves upon the application 
of heat. A sediment usually resembling red pepper, but sometimes of 
a brown color, consists of uric acid. It can be proved to be uric acid 
by the murexid test. The suspected material is placed in a crucible or 
evaporating dish with a few drops of nitric acid. As heat is applied the 
uric acid or amorphous urate dissolves with effervescence. Heat is now 
kept up until the material is evaporated to dryness; it is then allowed 
to cool. If now it be touched with a glass rod dipped in strong am- 
monia a characteristic blue or violet color is produced. Uric acid is not 
usually so abundant as the sediment of amorphous urates; it sinks more 
rapidly, and is deposited from acid, high-colored urines. 

A yellow or whitish sediment may consist of urate of soda. 

A white sediment usually consists of phosphates, associated with 
which sometimes is a white sediment consisting of urate of ammonia, 
with or without pus. Such urines are alkaline. A white sediment 
may be due to uric acid, especially in children. 

A yellowish- white sediment may consist of pus with or without 
mucus. If the urine be acid the sediment is loose and free to move, 
but when the urine is alkaline the sediment consists of a viscid, coherent 
mass, which can be drawn out into tough, stringy filaments. 

A chocolate-brown sediment occurring in a reddish smoky urine 
consists of blood from the kidneys. Clots of blood come from the 
ureters, bladder, or urethra. 

Odor. The odor of normal urine is sometimes spoken of as aromatic, 
but generally is sufficiently characteristic to be best described as urinous. 
When the urine is concentrated the odor is intensified, and may become 
unpleasantly strong, like that of the horse. 

Certain articles of food, such as garlic and asparagus, cause the urine 
to smell of sulphides. Turpentine, both when taken internally and in- 
haled gives to it the odor of violets. The odor of copaiba and of cubebs 
can easily be detected in the urine of patients who are taking them. 

In marked cystitis the natural urinous odor becomes more pungent, 
and is blended with a strong ammoniacal odor. When much pus is 
present and the urine has stood awhile the odor becomes putrid. 



638 



SPECIAL DIAGNOSIS. 



In diabetes mellitus the urine has a sweetish, hay-like odor. In 
diabetic coma the odor is sometimes that of chloroform, from the 
presence of acetone and diacetic acid. This odor, however, is more 
likely to be detected upon the breath. 

2. Chemical Examination of the Urine. Examination of the 
urine by the unaided senses, which has been dwelt upon thus far, is 
simply preliminary to an examination by chemical methods and by 
instruments of precision, particularly the microscope. 

Urea. Urea is freely soluble in water, and hence never appears as 
a sediment. It is the most important final product of nitrogenous dis- 
integration in the body, and an index of the eliminative power of the 
kidneys. Usually the density of the urine increases in proportion to the 
amount of urea contained in it. The average daily amount of urea 
excreted by an adult man between the ages of 20 and 40 is about 500 
grains. The urea, like the total volume of the urine, is subject to 
variations within the limits of health. It is increased after a meal, 
especially if it be rich in nitrogenous food ; after copious infusion of 
liquids, and by a close atmosphere. On the other hand, fasting, free 
perspiration, a loose condition of the bowels, and a vegetable or milk 
diet diminish the quantity of urea. Again, the quantity varies with 
the age of the person. According to Ralfe, at five years the amount is 
180 grains ; at 12, 320 ; at 21, 535 ; and at 40 years, 555 grains 

A large man will excrete absolutely more than a small man, and a 
large muscular man will excrete relatively more than a fat man of the 
same height. 

In disease, the urea is increased in fever and inflammatory diseases ; 
in diabetes mellitus and insipidus ; in malaria, pernicious anaemia, and 
after a crisis in pneumonia. It is increased also by certain beverages, 
as colfee, and by many drugs, especially those which act as hepatic 
stimulants. 

It is diminished in all forms of nephritis, especially when uraemia 
results ; in acute gout and chronic rheumatism ; in diseases accom- 
panied by emaciation and cachexia ; and in leprosy, pemphigus, melan- 
cholia, imbecility, catelepsy, hysteria, and cholera (Saundby). 

Estimation of Urea. For the methods employed in the exact quanti- 
tative estimation of urea, the student is referred to special works on the 
urine. 

For ordinary clinical purposes the instrument devised by Professor 
Charles Doremus, and known as his ureometer, gives sufficiently 
accurate results. The principle upon which it is based is that urea 
when brought in contact with sodium hypobromite is decomposed and 
free nitrogen eliminated. The nitrogen evolved is the measure of the 
urea contained in the urine. The instruments are graduated so that 
each division of the scale represents one grain of urea per fluidounce 
of urine. 

The hypobromite solution is made by dissolving 100 grammes of 
caustic soda in 250 c.c. of water and then adding 25 c.c. of bromine. 

It is better, however, to have the hypobromite solution made fresh 
for each examination. This can readily be done by having a solution 
of caustic soda containing six ouuces to a pint of water. It should be 



DISEASES OF THE KIDNEYS. 



639 



kept tightly corked with a rubber or paraffined stopper. The caustic soda 
solution is poured into the long tube of the ureometer to the mark =, 
then one-tenth of its volume of bromine is introduced by means of a 
pipette, and sufficient water added to fill the long arm and the bend of 
the tube. The hypobromite solution should fill the tube completely, and 
any bubbles rising to the top of the tube be got rid of before the intro- 
duction of the urine. The pipette is then filled with the urine up to 
the 1 c.c. mark, any urine adhering to its surface being carefully wiped 
off. The pipette is introduced carefully so as uot to compress the bulb 
until the point extends as high up as possible beyond the bend. The 
bulb is now compressed slowly, and bubbles of nitrogen rise to the sur- 
face of the long arm of the tube; when bubbles cease to be given off, 
the volume of nitrogen gas is read off as so many grains of urea per fluid- 
ounce of urine, or in milligrammes of urea in 1 c.c. of urine, accord- 
ing to whether it is graduated by the English or the metric system. 

Detection and Estimation of the Chlorides. The presence or 
absence of chlorides is sometimes of diagnostic value. They are increased 
when absorption of exudations or transudations is going on, and in 
malarial fevers, diabetes insipidus, and Bright' s disease. They are dimin- 
ished or absent in pneumonia during its progressive stage, and in fevers. 
The chlorides can be detected and roughly estimated by an eight or ten 
per cent, solution of nitrate of silver. A few drops of nitric acid are 
first added to the urine to prevent the silver from also throwing down 
the phosphates. A single drop of the silver solution mentioned will 
precipitate the chlorides in a thick white lump, which falls to the bottom 
of the test-tube, provided they are present in the normal amount. If, 
on the other hand, they are diminished to one-tenth per cent, or less 
they will not be precipated in a lump or lumps, but as a white cloud 
which renders the whole solution opaque. If no precipitate whatever 
occurs the chlorides are absent. 

Detection and Estimation of Serum-Albumin. Albumin is a 
very common, but it cannot be looked upon as a normal constituent of 
the urine, though its presence by no means necessarily indicates disease 
of the kidneys. The ordinary form is serum-albumin, but other pro- 
teids, as globulin, mucin, peptone, albumose, haemoglobin, fibrin, and 
methsemoglobin are found at times. The most trustworthy tests for 
ordinary albumin (serum-albumin) are: boiling, with the addition of 
acetic acid or nitric acid ; overlaying cold nitric acid with urine (Heller's 
test) ; and the picric acid test. 

Boiling and Acetie Acid Test. A narrow long test tube is filled two- 
thirds full of urine and the upper third boiled thoroughly, and then 
a few drops of dilute acetic acid added. Any albumin present will 
be coagulated and appear as a white cloud contrasting strongly with 
the clear unboiled urine beneath it. When the albumiu is moderate or 
small in amount it can be detected without difficulty by simply holding 
the test-tube up to the light. When there is a faint trace present it 
will be overlooked unless the tube be laid against a dark surface in 
such a way that the light falls upon it from above, in front and pre- 
ferably slightly to one side. A cloud may escape detection when looked 
for by artificial light, but be distinct by daylight. Serum-globulin is 



640 



SPECIAL DIAGNOSIS. 



also thrown down by this test. But the globulin is not often present 
by itself, and its significance is not yet understood It may be detected 
in any urine, as Roberts points out, by diluting the urine with pure water, 
the urine then becoming more or less milky. It may be eliminated 
from urine by saturating the latter with sulphate of magnesia and filter- 
ing. The presence of serum-globulin in no way interferes with the test 
for serum-albumin. 

If the urine is opaque from amorphous urates, it is unnecessary to 
filter them out; heat much below boiling will dissolve them, the precipi- 
tate from albumin occurring later. 

If the urine is alkaline or faintly acid, phosphates will produce a cloud 
upon heating the urine; but they are instantly dissolved upon the addi- 
tion of a few drops of acetic acid. 

Mucin produces an opalescence upon heating with an organic acid, 
but Saundby declares that it coagulates not as albumin, but in the form 
of tiny filaments. 

Boiling and Nitric Acid Test. This is preferred by many to the 
former. It is performed in a similar way ; but the nitric acid so dis- 
colors many urines that the detection of small amounts of albumin is 
interfered with. 

The Nitric Acid Test. This test, while not so delicate as the acetic 
acid test, is very simple and beautiful in its results. Cold nitric acid 
is poured into a test-tube to the depth of about an iuch. The tube is 
then inclined to an angle of about 45 degrees, and urine allowed to flow 
gently down upon the acid by trickling along the side of the tube from 
a pipette or glass tube guarded by the finger. At the level of contact 
of the acid and urine a zone of white coagulated albumin forms. The 
thickness of the white zone is generally an index of the amount of 
albumin present. If there is barely a trace of albumin half an hour 
may be required to develop any opalescence. 

A cloud of urates is sometimes thrown down and obscures the test. 
This cloud does not, however, begin at the level of contact and extend 
upward, but at the upper level of the urine and extends downward, and 
it is dissipated by heat. 

Patients who are taking copaiba or cubebs pass a urine which gives 
a white ring at the point of contact with cold nitric acid, but heat 
diminishes the opacity, and the odor of the drugs named aids to their 
detection. 

The Picric Acid Test. This is an extremely delicate test for albumin. 
A saturated solution of picric acid is allowed to flow down upon, and 
the upper layers slightly mix with, the urine which half fills a good- 
sized test-tube. At the level of contact an opaque white ring of coagu- 
lated albumin is formed. If no ring appears albumin is pretty certainly 
absent. Hence, the picric acid test is a valuable negative test. But, 
unfortunately, a ring is formed by peptone, mucin, and the presence in 
the urine of various alkaloids, particularly quinine. The latter disap- 
pears upon the application of heat, whereas an opalescence due to 
albumin becomes diffused throughout the whole urine. 

Of the three tests, the first by boiling, with the subsequent addition of 
dilute acetic acid, is to be preferred. It is more delicate than the cold 



DISEASES OF THE KIDNEYS. 



641 




nitric acid test, and it is free from the risk of burning one's fingers and 
clothes, which nitric acid always entails. The latter point is not an 
inconsiderable one for a physician who is obliged to make his urinary 
examination in his office whenever he can find time. The boiling and 
acetic acid test is to be preferred to the picric acid test as being just as 
easy of performance, and being at the same time free from the fallacies 
of the latter. 

In all the tests for albumin mentioned a clear urine is necessary, espe- 
cially when the amount of albumin is very small. This can be obtained 
by filtration when the opacity is due to pus, blood, mucus, 
and uric acid; and more effectively by the addition of 
liquor potassse, heating, and filtering, If the filtrate in 
the latter case is not clear, a few drops of magnesian fluid 
(sulphate of magnesia, pure ammonium chloride and pure 
liquor ammonise, of each 2 drachms ; distilled water, 2 
ounces) as recommended by Hoffmann and Ultzmann, 
can be added, and the urine again warmed and filtered. 

The quantitative estimation of albumin is of some im- 
portance. The most direct method is to coagulate the 
albumin by boiling, catch it upon a weighed filter, wash, 
dry, and weigh it. Such a process, however, consumes 
too much time for clinical purposes, and it is not fault- 
less. An approximate estimation can be made by boil- 
ing the urine in a test-tube, allowing the albumin to 
settle, and then comparing the depth of albumin with the 
column of urine. In this way we can speak of urine con- 
taining one-tenth or one-quarter of its bulk of albumin. 

Esbach has invented an albuminometer which gives 
better results. The solution used to precipitate the 
albumin consists of 10 grammes of picric acid and 20 
grammes of citric acid, chemically pure, and dry, dis- 
solved in 1000 grammes of hot water ; any loss by cool- 
ing is to be made up by adding water sufficient to make 
one litre — 1000 grammes. The urine is diluted with a 
definite amount of water if it contains too much albumin. 
The albuminometer is filled to the mark U, and from 
that level to R with the reagent. The tube is then corked 
with a rubber stopper, turned upside down ten times, so 
as to mix the urine intimately with the reagent, and then 
allowed to stand undisturbed for twenty-four hours. At 
the end of this time the level of coagulated albumin is 
taken according to the scale cut upon the glass. Each 
mark corresponds to one-tenth per cent, of albumin. 

This estimation, as already stated, is not absolutely 
accurate. Nevertheless, if one always uses it, and in the same way, 
relative values will be obtained, and these are the most important in 
watching the progress of a case, as they give positive information 
regarding an increase or diminution of the amount of albumin in the 
urine. It scarcely need be said that the urine tested must be a sample 
of the whole twenty- four hours' urine. 

41 



Esbach's albumi- 
nometer. 



642 



SPECIAL DIAGNOSIS. 



Albuminuria. Albuminuria is not indicative of disease of any one 
organ, nor does it point to any general pathological condition. It occurs 
as follows : 

1. In diseases of the kidney : acute and chronic Bright's disease, 
amyloid disease, tubercle, cancer, abscess, and calculus. 

2. Iu disturbances of the circulation : diseases of the heart and 
chronic pulmouary diseases, as emphysema ; obstruction of the renal 
arteries or veins, cirrhosis of the liver, peritonitis, pregnancy, abdominal 
tumors ; in passive congestions due to great weakness ; in anaemia and 
Graves' disease. 

3. In febrile and inflammatory diseases : in the eruptive and infec- 
tious fevers, and in rheumatism, diphtheria, pneumonia, and gout. 

4. In blood diseases : purpura, leucocythsemia, and scurvy. 

5. From the poisonous action of drugs : lead, turpentine, and others. 

6. In nervous disorders : concussion of the brain and cerebral hem- 
orrhage, epilepsy, tetanus, and delirium tremens ; as Pye-Smith remarks, 
it is doubtful whether albuminuria is caused by the nervous disease. 

7. Local extra-renal affections : pyelitis, cystitis, gonorrhoea, and 
leucorrhcea. 

8. Functional. In young persons, particularly of the male sex, 
there occurs occasionally a small albuminuria after exercise, a special 
diet, or a cold bath. Albumin may be found after rising in the morn- 
ing, or early after dinner or toward evening. On account of its occur- 
rence only at certain times it has been called " cyclical " or " intermit- 
tent/' and because there is no evident disease present, it is occasionally 
spoken of as " physiological " albuminuria. 

Goodhart examined the urine of 1500 individuals and noted albu- 
min in 272, or in 20 per cent. In 39 cases the albuminuria could not 
for certain be said to be due to disease of the kidney. Of these 39, 
26 were males and 13 females. In 32 of the 39 cases it was tempo- 
rary, and in most of them it had disappeared within forty-eight hours, 
or sooner. In 2 cases there were oxalates in the urine ; in 1 hsemo- 
globinuria; in 8 leucorrhoeal discharges and discharges from other 
parts of the genital passage (see division 7); and in 17 a markedly 
neurotic temperament. These last he thinks the most typical cases of 
intermittent albuminuria, while he regards the condition as less common 
than has been supposed. 

A variety of functional albuminuria is due apparently to the irrita- 
tion of the kidney produced by the excretion of oxalates and uric 
acid. The urine is of increased density, 1028, 1030 or higher, con- 
tains uric acid or oxalate of lime, or both, and cylindroids. Tube- 
casts are very uncommon. The albuminuria usually disappears under 
proper diet. 

It is conceded that there may be albuminuria of renal origin without 
renal disease, but the diagnosis must be by exclusion, and can be 
reached safely only after extended observation. The most important 
elements in the diagnosis are the age of the patient, unimpaired general 
health, a specific gravity of the urine normal or above normal, the fact 
that the albuminuria is influenced by diet and exercise, and that it tends 
to disappear under suitable regimen. The prognosis is favorable. 



DISEASES OF THE KIDNEYS. 



643 



Peptone. Peptone occurs in the urine in a variety of conditions, and 
hence not much diagnostic value can attach to its detection. According 
to Von Jaksch, its presence may indicate that a suppurative process 
exists ; and when the diagnosis lies between epidemic cerebro-spinal 
meningitis and tubercular meningitis, the presence of peptonuria speaks 
for the former, but only when ulcerative processes in other organs, 
especially in the lungsj can with certainty be excluded. Exact tests for 
its detection are too elaborate for clinical purposes. The late Dr. N. A. 
Randolph suggested the following test, which is given by Tyson : To 
five c.c. of urine, which must be cold and faintly acid, add two drops 
of a saturated solution of potassium iodide and then three or four drops 
of Millon's reagent. If peptones or bile acids are present a yellow 
precipitate falls. If the yellow sediment does not respond to the test 
for bile acids it is due to peptone. 

Picric acid when allowed to overlay urine containing peptone pro- 
duces a white hazy ring which, unlike albumin, disappears upon the 
application of heat. If the patient has taken no vegetable alkaloids, 
particularly quinine, the ring described may be assumed to be due to 
peptone. Nitric acid and heat do not precipitate peptone. 

Mucin. Small quantities of mucin are present in all urines, being 
usually more abundant in women, from the admixture of the vaginal 
secretion. It is increased in catarrhal affections of the genito-urinary 
passages and of the bladder. It is thrown down by organic acids, but 
not by nitric acid. 

According to Roberts, the best way to detect mucin is by means of a 
saturated solution of citric acid, employed in the same way as the con- 
tact method of applying the nitric acid test for albumin. A small 
quantity of the urine is first put in a test-tube and citric acid allowed 
to trickle along the sides of the tube until it forms a distinct layer 
below the column of urine. If mucin be present there will gradually 
appear an opalescent zone immediately above the layer of acid. Acetic 
acid mixed with one-third of its bulk of glycerin answers perfectly as 
a mucin test. Sometimes when mucin is very abundant the free addi- 
tion of acetic acid without any precautions produces a marked milki- 
ness of the urine. It is not re-dissolved by boiling. 

Blood. Urine containing blood is usually red in color or reddish- 
brown and opaque, but it may be chocolate-brown if the blood is 
abundant and has been acted upon by the urine. It contains albumin. 

Blood occurs in the urine from (1) diseases of the kidney and urinary 
passages, among which are Bright's disease, acute congestion of the 
kidney, renal calculus, cancer, tubercle ; from ureteritis, cystitis, and 
urethritis, and from injuries ; (2) from general diseases, such as the 
eruptive and intermittent fevers, scurvy, purpura, peliosis rheumatiea, 
leucocythsemia, cholera ; (3) from adjacent organs, as in menstruation 
and hemorrhage from the uterus ; (4) from the toxic action of drugs — 
cantharides, turpentine, and other violent irritants of the kidney; 
(5) vicariously — occasionally menstruation fails to occur and hematuria 
replaces it. The same is true of bleeding from piles. Latour has 
reported a case of asthma which subsided suddenly upon the appear- 
ance of hematuria. 



644 



SPECIAL DIAGNOSIS. 



The chemical tests for blood are those for its coloring matter, and 
they will be referred to under Haemoglobin. 

Haemoglobin. Haemoglobin is of course present whenever blood is, 
but sometimes it occurs independently of hematuria. Thus it is found 
in grave infectious diseases, as the result of toxic action of drugs, such 
as carbolic acid, and in an independent disease known as paroxysmal 
hemoglobinuria. A suitable test consists in adding one or two drops 
of fresh tincture of guaiac to about one drachm of urine ; then shake 
the mixture and add a half-drachm of ozonic ether (i. e., sl solution of 
peroxide of hydrogen in sulphuric ether). 

The same test answers for niethsemoglobin and hsematin. 

Paroxysmal Hemoglobinuria. The urine is bloody, or the coloring 
matter only is present. It is more frequent in males, and occurs 
in adults. It may be excited by a cold bath, or exposure to cold, 
and by exertion. It is sometimes associated with Raynaud's disease. 
The attacks come on suddenly, often preceded by chills. There is some- 
times fever. Vomiting and diarrhoea occur with the hemoglobinuria. 
Pain in the loins is sometimes complained of. The paroxysm may last 
a day or two, or two or three occur in the course of twenty-four hours. 

Albumose. Albumose has been found in the urine in osteomalacia 
and diseases of the medulla of bone, in dermatitis, intestinal ulcer, 
measles, scarlatina, and mental diseases. Urine containing it does not 
respond at first to the heat and nitric acid test, but on cooling a precipi- 
tate forms which responds to the biuret test. (In this test the urine is 
first treated with caustic potash, and then a 10 per cent, solution of 
sulphate of copper added, drop by drop. If albumin be present the 
resulting peroxide of copper is dissolved, and the fluid becomes of a 
reddish-violet color.) The probability of the presence of albumose is 
strengthened if a turbidity occurs with the acetic acid and ferrocyauide 
of potassium test (acetic acid, specific gravity 1064, to which a few drops 
of a 10 per cent, solution of ferrocyanide of potassium has been added), 
and also with the biuret test, applied directly to the urine itself. 

Detection and Estimation of Sugar. Next to albumin, sugar is 
the most important abnormal constituent of the urine. It is not present 
in normal urines in quantities that can be detected by ordinary clinical 
methods. The best tests for its detection are that by Fehling's solution 
and the fermentation test. 

Fehling's Test. Fehling's solution is made as follows : Sulphate of 
copper, 90J grains ; neutral tartrate of potash, 364 grains ; solution ot 
caustic soda (sp. gr. 1.12), 4 fluidounces; water sufficient to make 
exactly 6 fluidounces. Two hundred grains of this solution, according 
to Roberts, are decomposed by one grain of sugar. 

Certain precautions are necessary in the application of this test. 1. 
Any albumin present must be removed by boiling and filtration. 2. 
The Fehling solution is to be boiled first and the urine added to it ; do 
not boil the urine first and then add the Fehling solution. Boiling the 
reagent first is a test of its stability ; if a precipitate occurs the solution 
is unfit for use until soda or potash has been added to it and it has been 
filtered. As Tyson correctly says, a precipitate upon boiling the solu- 
tion alone is more likely to occur when the Fehling solution has been 



DISEASES OF THE KIDNEYS. 



645 



diluted with three or four times its bulk of water. 3. Prolonged 
boiling is to be avoided. Heat the solution to boiling and then add the 
urine ; if no precipitate indicating sugar occurs until urine is added 
almost equal in bulk to that of the reagent, heat the mixture again to 
boiling and then set aside. 4. When the earthy phosphates are abun- 
dant it is well to get rid of them by adding liquor potassae and filtering 
before applying the sugar test. 5. Changes in color occur from the 
presence of urea, uric acid, and extractives. These changes can be 
obviated when necessary by the method proposed by Seegen, who recom- 
mends repeated filtering through animal charcoal until the urine comes 
out colorless. The filter is then washed with distilled water and the 
sugar test applied to the water. 

The method of applying the Fehling test is so clearly given by Roberts 
that one cannot do better thau reproduce his words : " Pour some of 
the prepared test liquor, Fehling's solution, into a narrow test-tube to 
the depth of three-quarters of an inch ; heat until it begins to boil, then 
add one or two drops of the suspected urine. If it be ordinary diabetic 
urine, the mixture after an interval of a few seconds will turn suddenly 
of an intense opaque yellow color, and in a short time an abundant yellow 
or red sediment falls to the bottom. If, however, the quantity of sugar 
present be small, the suspected urine is added more freely, but not beyond 
volumes equal to that of the test employed. In this latter case it is 
necessary to raise the mixture once more to the boiling-point. It is 
then allowed to cool slowly. If no sub-oxide has been thrown down 
when it has become cold, then the urine may with certainty be pronounced 
sugar-free." Again he says : " If no milkiness is produced as the mix- 
ture cools the urine may be confidently pronounced free from sugar, for 
no quantity above a fortieth of a grain per cent, can escape such a 
search, and any quantity below that is devoid of clinical significance." 

The Fermentation Test. This is based upon the fact that yeast by 
fermentation separates sugar into alcohol and carbonic oxide. It is a 
certain but not very delicate test for sugar. 

A small piece of yeast-cake is added to a test-tube full of urine. The 
tube is inverted under water in a saucer or beaker. If sugar is present 
in amounts larger than two and a half grains to the ounce, bubbles of 
carbonic oxide collect at the upper part of the tube after standing twelve 
hours in a temperature of about 90° F. 

The Phenyl-hydrazin Test. Von Jaksch believes this test to be a very 
accurate one. About two grains of hydrochlorate of phenyl-hydrazin 
and three of acetate of soda are put into a test-tube half full of water. 
The contents of the tube are heated and the tube filled with the sus- 
pected urine. The tube is kept for fifteen or twenty minutes in boiling 
water, and then put in a vessel of cold water. When a large amount 
of sugar is present a deposit of yellow needle-like crystals is visible to 
the naked eye ; but when only a small amount is present the sediment 
needs to be examined under the microscope. The crystals appear singly 
or in sheaves and fine radii. Yellow plates and brown balls do not 
indicate sugar. (Fig. 93.) 

Quantitative estimation of sugar can be made with Fehling's solution 
by using a burette and measured quantities of urine and reagent. Tyson 



646 



SPECIAL DIAGNOSIS. 



recommends a method which answers very well for office use : One cubic 
centimetre of Fehling's solution is diluted in a large test-tube with four 
cubic ceutimetres of distilled water, and boiled. Oue-tenth of a cubic centi- 
metre of the suspected urine is then added from a graduated pipette. Heat 
is then applied, the precipitate watched, and then another cubic centimetre 
added, and heat again reapplied until it is found, after proper subsi- 
dence, that all the color is removed from the cubic centimetre of Fehling's 
solution. If in doing this one cubic centimetre of urine has been added, 
it will have contained just one-half of 1 per cent, of sugar. If more than 
one cubic centimetre it will have contained less than one-half, but more 
than one-quarter per cent. If exactly two cubic centimetres are used, 
it will have contained exactly one-quarter per cent. If the quantity of 
sugar in the urine is large, the urine should first be diluted with a 
measured volume of water, this being regarded in the estimation. 



Fig. 93. 




Crystals of phenyl-glucosazon. (Von Jaksch.) 



When the quantity of sugar is relatively, large fermentation is the 
simplest and most trustworthy method. Roberts has shown that 
saccharine urine loses by fermentation one degree in density for every 
grain of sugar contained in an ounce of urine. For example, if the 
urine before fermentation had a specific gravity of 1040 and after fer- 
mentation a specific gravity of 1010, then the urine contained thirty 
grains of sugar to the ounce. In the application of this method about 
four ounces of the saccharine urine are put into a twelve-ounce bottle 
and a lump of German yeast about the size of a small walnut is then 
added to it. This bottle is closed with a perforated cork to allow the 
C0 2 to escape, and stood aside in a warm place to ferment. Beside it 
is placed a tightly corked four-ounce bottle filled with the same urine, 
but without any yeast. In about twenty-four hours the fermentation 



DISEASES OF THE KIDNEYS. 



647 



will have ceased. The specific gravity of the fermented urine is then 
taken and also that of the unchanged urine. Every degree of loss of 
density represents one grain per ounce of urine. 

Indican. An excess of indican is known as indicanuria. The sub- 
stance is detected by several methods. Jaffe's test : Equal parts of 
hydrochloric acid and urine are mixed. By means of a glass pipette a 
solution of hypochlorite of soda is dropped into the fluid. An indigo- 
blue color is obtained. The hypochlorites must not be in excess. Weber's 
test is as follows : To 30 c.c. of urine and hydrochloric acid add 1 to 3 
drops of dilute nitric acid. A quantitative examination is made by 
the colorimetric process of Salkowsky. A rough analysis is first made 
to determine the quantity of chlorinate of lime which causes the great- 
est abundance of indigo to unite with it. If the urine contains much 
indican, a small portion, as 2.5 to 5 c.c, is diluted with water to 10 c.c. 
If there is but little indican, 10 c.c. of the urine is used without dilu- 
tion. Add to the fluid an equal quantity of hydrochloric fluid. To 
this add the amount of chlorinate of lime solution with which in the 
first test indigo formed in the greatest abundance. First neutralize the 
liquid with caustic acid, and then add enough carbonate of soda to make 
it alkaline. The indigo-blue is precipitated on filter. Repeatedly wash 
with water until the alkaline reaction disappears. The filtrate is dried 
and extracted by heating with chloroform until the latter does not take 
up its color. The chloroform extract is increased to a round number 
of c.c. by the addition of chloroform, and placed in a vessel with parallel 
sides. The intensity of its color is compared with a freshly prepared 
chloroform solution of indigo-blue of known strength. To one or other 
of these, chloroform is added until the tint of each is equal. The 
quantity of indigo-blue derived from the urine is determined and its per- 
centage calculated from the constitution of the standard solution. Five 
to twenty milligrammes of indigo-blue are passed in twenty-four hours in 
health. When the mixture is boiled, a dark color is assumed. Allow 
the mixture to cool, and then shake up with ether. The indigo-blue is 
seen as a blue froth on the surface, while the ether is of a rose or violet 
tint. Indican is increased by animal diet — an increase which under 
other circumstances is pathological. Its presence is a sign of iutestinal 
putrefaction. It may accompany a decomposition of albumin in cavi- 
ties. It is present in empyema and in puerperal peritonitis. By 
detection of its presence in these, cavities due to pus may be distin- 
guished from those due to other causes. Indican is increased in acute 
diarrhoea and in intestinal tuberculosis. Von Jaksch states that large 
quantities of indican in the urine imply that abundant albuminous 
putrefaction or putrid suppuration is in progress in the system. It must 
not be forgotten that in simple constipation indicanuria will often arise. 

Bile Pigments and Bile Acids. Bile pigment or bilirubin occurs 
in the urine in cases of hepatogenic and hematogenic jaundice and in 
portal thrombosis. 

Gmelin's test and its modifications are the ones usually employed. 
A small quantity of nitric acid, to which some nitrous acid has been 
added, is put into a test-tube and then gently overlaid with urine. If 
bile pigment is present a series of colors appear at the junction of the 



648 



SPECIAL DIAGNOSIS. 



two fluids — green, blue, violet and yellow. A green color (biliverdin) 
must be present to prove the existence of bile pigment. 

The same test can be applied by placing a few drops of the acid 
upon one side of a plate and the urine on the other, and then allowing 
the two to run together. The play of colors takes place, as before, at 
the line of junction of the acids and urine. 

Posenbach's modification is an improvement. About 200 cubic cen- 
timetres of urine are allowed to flow through pure white filter paper, 
and then a drop of nitric acid is placed upon the paper saturated with 
the urine. The colors appear as before. 

A very simple test consists in allowing a few drops of the acid to fall 
into a test-tube full of urine. If bile pigment is present a green color 
appears at the line of junction of the two fluids. If only small quan- 
tities of bile pigment are present, this test may fail to show it. 

The tests for bile acids are either too elaborate or too unsatisfactory 
for clinical use. 

Pus. Pus is found in the urine whenever there is suppuration or a 
catarrhal condition of the genito-urinary tract. Hence it occurs in 
abscess of the kidney, pyonephrosis, pyelitis, tubercle, cystitis, gonor- 
rhoea, leucorrhoea, etc. It is relatively common in women, from a 
catarrhal condition of the vulva and vaginal mucous membrane, and 
hence in them is of less significance than it is in men. Urine contain- 
ing much pus is slightly albuminous ; but frequently pus cells are 
found in urine which gives no reaction for albumin. 

The chemical test for pus is its conversion into a tenacious (gelatin- 
ous) glairy mass by boiling with caustic potash. 

Acetonuria. An excess of acetone occurs in the following dis- 
eases : 1. In diabetes ; 2, in cancer independent of starvation ; 3, in 
starvation ; 4, in certain psychoses ; 5, in auto-intoxications ; 6, in 
derangement of digestion ; finally, 7, in fevers. In diabetes acetone 
indicates an advanced stage of the disease. Lieben's test is recognized 
by Von Jaksch : To several c.c. of urine a few drops of iodo-potassic 
iodide solution and caustic potash are added. If acetone is in excess, a 
large precipitate of iodoform crystals takes place. 

Diaceturia. Diacetic acid is found in the urine in diabetes, in 
fevers, and in auto-intoxications. It is common with children in fever. 
It is of grave significance when in the urine of adults. Coma usually 
follows its passage in fevers and in diabetes. Test : Cautiously add a 
concentrated solution of perchloride of iron. Remove the filtrate if it 
is formed, and add more of the iron solution. Bordeaux-red color is 
developed. After the color appears divide the solution into two parts. 
Boil one part. If there is no change, test for acetone. The presence of 
this substance indicates that diaceturia is present. 

Microscopic Examination of the Urine. Microscopic examina- 
tion of the urine is chiefly concerned with the sediments, and these are 
conveniently divided into organized and unorganized. 

The organized deposits in the urine are blood, pus, mucus, epithelium, 
casts, spermatozoa, micro-organisms, cancerous and tuberculous matter, 
entozoa. 



DISEASES OF THE KIDNEYS. 



649 



The unorganized deposits are uric acid and its compounds, oxalate and 
carbonate of lime, phosphates, leucin and tyrosin, cystin and cholesteriD. 

Normal urine forms a slight sediment consisting of epithelium from 
different parts of the genito- urinary tract, principally from the bladder 
in males, and from the vagina and bladder in females. There are also 
some crystals of the different urinary salts, sometimes mucus and a 
few white blood-cells, and if the urine has stood awhile, especially if 
alkaline, more or fewer bacteria. It may accidentally contain extraneous 
matter derived from the vessel which contains it or from the air. 
(Fig. 94.) 

Fig. 94, 




Extraneous matters found in urine : a, cotton fibres ; b, flax fibres ; c, hairs ; d, air bubbles ; 
e, oil globules ; /, wheat starch ; g, potato starch ; h, rice-starch granules ; i i i, vegetable tissue ; k, 
muscular tissue ; I, feathers. 



Organized Sediments. 1 Blood. If the blood comes from the 
kidney it is usually intimately mixed with the urine, which remains of 
a red or reddish-brown color, and contains possibly tube-casts and renal 



1 The use of the centrifugal machine in obtaining urinary sediment is of much practical value, 
and the writer highly recommends it. Not only is much time saved in completeing the examina- 
tion of the urine, but all danger of its undergoing fermentation is avoided. The sediment can be 



650 



SPECIAL DIAGNOSIS. 



epithelium. The blood-cells appear singly, have frequently lost their 
haemoglobin, and hence look like pale yellow disks. (Fig. 95.) Some- 



FlG. 95. 




Blood corpuscles in urine, a, slightly distended by imbibition ; b, showing 
their biconcave contour ; c, shrivelled ; d, serrated. (Roberts.) 

times blood coagulates in the ureters, and long cylindrical plugs are 
passed, causing symptoms resembling those of renal colic. "When blood 
comes from the bladder or neck of the bladder (fissure) there are symp- 



FlG. 96. 




Mould fungus. Sporules and thallus. (Roberts.) 

toms of frequent micturition, of acute pain and tenesmus, and the blood 
is not intimately mixed with the urine. When from the neck of the 
bladder it often occurs in a few drops at the end of micturition, 



thrown down in three minutes' time by means of the machine without injuring casts or other 
contents. In using the machine, one of the glass tubes is three-fourths filled with the urine under 
examination and the handle revolved rapidly for about three minutes, or until three hundred 
revolutions have been made. The sediment will be found in a compact mass at the bottom, and 
is removed by a pipette and examined as detailed above. 

For the preservation of urine until a sediment sufficient for examination is found, resorcin is the 
best antiseptic. A solution of fifteen grains to the drachm is made. One-half drachm will preserve 
four ounces of urine many days. 



DISEASES OF THE KIDNEYS. 



651 



accompanied with great pain and a sense of faintness. Intermittent 
hematuria, according to Von Jaksch, points directly to calculus or tumor 
of the bladder. 

Blood-cells when unaltered are unmistakable on account of their well- 
known biconcave appearance. When they have lost their coloring 
matter they appear as circular, very pale disks, with extremely faint 
outline and feeble refractive power. Absence of a nucleus serves to distin- 
guish them from yeast spores (Fig. 96), and the latter, moreover, are often 



Fig. 97. 




Dumb-bells and ovoids of oxalate of lime. (Roberts.) 



oval in shape. They are less likely to be confounded with the ovoid 
and circular shapes of oxalate of lime crystals, because the latter are 
not common aud can be seen usually in their more common forms as 
octahedra and dumb-bells in the same urine. (Fig. 97.) 



Fig. 98. 




Pus corpuscles, a, without reagents ; b, after the addition of acetic acid. (Roberts.) 

Pus. The sources of pus in the urine have been referred to already. 
The pus corpuscle is an opaque, spherical, granular cell, usually some- 



652 



SPECIAL DIAGNOSIS. 



what larger than a red blood-cell. In dilute urine or upon the addi- 
tion of water it swells sometimes to twice its original size. At the 
same time it becomes less granular, and two, three, or four nuclei may 
appear. In concentrated urines the pus cell is small. The addition of 
acetic acid also, causes it to swell and brings out the nuclei more dis- 
tinctly and rapidly. Sometimes the pus cells are discrete, sometimes in 
dense clumps, and sometimes nothing but a dense mass of pus cells 
appears in the field of the microscope. (Fig. 98.) 

It cannot be decided from microscopic examination whether a cell is 
a pus corpuscle, a mucus corpuscle, a white blood-cell, or an inflam- 
matory leucocyte. It must be a matter of inference from the general 
characters of the urine. If red blood-cells are also present, the prob- 
ability of finding white blood-cells is increased, but pus cells are not 
necessarily excluded. So, too, if much mucus be present in the urine, the 
doubtful cell may be a mucus corpuscle. Some clue to the source of 
the pus can be obtained from the urine itself. Urine containing pus 
from the kidney is usually acid, whereas in cystitis it is alkaline and 
almost always contains phosphates, mucus, and abundant bacteria. 
Again, pus from the kidney or kidney pelvis is apt to vary greatly in 
amounts, or be discharged intermittently ; and the urine when filtered 
free of pus cells is usually still albuminous. Renal epithelium and 
casts also may be found. 

Casts. Casts are the most important of the urinary deposits. They 
vary greatly in number and size. Sometimes in acute nephritis they 
form a considerable part of the sediment, but usually they have to be 
sought for carefully and patiently. A few words as to the method of 
examining for them may not be superfluous. 

Six or eight ounces of the urine to be examined should be allowed to 
settle in a bottle as soon after being passed as possible. The bottle 
should be tightly corked, because urine exposed to the air decomposes 
very quickly ; and it should be sent to the person who is to examine it 
as soon after being passed as possible in order that an examination can 
be made before fermentative changes spoil it for trustworthy analysis. 
After standing twelve, or preferably twenty-four hours, nearly all the 
solid matter will have collected in the bottom of the bottle. The 
supernatant clear fluid can now be poured off and the lower portion of 
the urine and the sediment poured into a conical subsiding-glass. If 
the urine is febrile there may be by this time a large deposit of amor- 
phous urates which will obscure the search for casts ; they may be 
dissolved by gentle heating without destroying the casts, and the clear 
urine again allowed to settle for a few hours. So, too, if phosphates are 
abundant, they should be got rid of by gentle heating and acidulation 
with two or three drops of dilute acetic acid. 

After the urine in the conical subsiding-glass, which will not now 
amount to more than an ounce or two, has stood for a few hours, any 
casts that may be present will have fallen to the bottom. If the urine is 
very concentrated (1030 or more), epithelium, blood, and casts will be sus- 
pended longer; hence it may be well to dilute the urine before allowing 
it to settle. 



DISEASES OF THE KIDNEYS. 



653 



A glass tube with an internal diameter of about one-eighth of an 
inch, and with one end drawn out fine, is the most convenient thing for 
collecting the sediment. The ordinary glass pipette with a rubber 
suction-bulb at one end, commonly known as a " medicine dropper/' 
sometimes answers admirably. If the common glass tube is used, the 
forefinger of the right hand should be placed over the open upper end, 
and the fine lower end passed down to the bottom of the glass. The 
finger is then removed sufficiently to permit a few drops to be sucked 
in. The same result is attained if the finger is entirely removed as 
soon as the point of the tube reaches the bottom of the conical glass ; 
but in that case more than the lowest layers of the sediment or urine 
are sucked up, and hence all but a few drops should be allowed to flow 
out when the tube is removed from the urine. In this way the drops 
preserved for microscopical examination will contain the sediment from 
the very bottom of the glass ; and in this sediment, in pale urines free 



Fig. 99. 




Epithelial and hyaline casts. 



from much urates, phosphates, and pus, the casts will be found, if any 
are present in the urine. It is most important to examine the bottom 
layers of the sediment when the latter is scanty or when phosphates or 
urates have begun to precipitate after the urine has been standing some 
time. If the urine is already cloudy with phosphates, urates, or pus 
when it is put aside to settle, any casts that may be present will be 
carried down with the heavier sediment and will be found intimately 
mixed with it, or even on top of the other sediment. 

The few drops preserved for microscopic examination are now 
deposited on several slides, covered with a cover-glass in the usual way, 
and examined carefully for casts under a power of 200 or 300 diameters. 
Casts may be numerous, so that nearly every field contains one or more, 
or they may be very few, not more than one or two being found on a 
slide. 

When great importance attaches to the examination it is better to use 
a square cover-glass, so that starting, say, from the upper left-hand 
corner, and moving the slide slowly, keeping the upper edge in view, 
until the upper right-hand corner is reached, and then taking a field 



654 



SPECIAL DIAGNOSIS. 



lower down and running the slide in the opposite direction until the 
left edge is again reached, and so on, the whole slide can be examined, 



Fig. 100. 




Hyaline and waxy casts, a, From a case of chronic Bright's disease of eight months' duration. 
b, From a case of chronic Bright's disease (large white kidney), c, From a case of chronic Bright's 
disease (contracted kidney with fatty degeneration). (Roberts.) 

and one can positively say whether casts are or are not present in that 
particular slide. If the ordinary circular cover-glass is used, the same 



Fig. 101. 




a, Epithelial casts, b, Opaque granular casts, from a case of acute Bright's disease. (Roberts.) 

field may be re-examined several times and other parts of the slide never 
seen. All the pipettes used in examining urine must be kept clean. 



DISEASES OF THE KIDNEYS. 



655 



They should be allowed to stand in water which is frequently changed, 
and carefully rinsed in running water before being used. 

Tube-casts usually indicate acute or chronic nephritis ; but they are 
sometimes found in cases of renal calculi ; in icterus, usually without 
albuminuria ; in diabetes, and sometimes in secoodary congestion of the 
kidney. 

Several varieties of casts are found. 1. Hyaline casts, as their name 
implies, are clear, translucent bodies, which refract light so slightly that 
they are easily overlooked. They have well-defined margins, the ends 
being frequently rounded ; they are rarely very long, and are straight, or 
but slightly bent. They are rarely equally translucent throughout; 
at some part more or less granulation will generally be found. In size 
they vary in diameter from that of a white blood-cell to six or eight 



Fig. 102. 




a, Fatty casts ; & and c, blood-casts ; d, free fatty molecules. (Roberts.) 

times as large. They can be stained and so rendered more distinct by 
allowing a drop of gentian-violet solution to flow in under the edge of 
the cover-glass. (Figs. 99, 100, a a.) 2. Granular casts are hyaline casts 
which appear granular either from some deposit on their surface or 
from a granular change of the cast itself. When the granulation does 
not interfere with the translucency, the casts are described as " pale " 
or "slightly" granular; and when they become very dark, so as to 
resemble closely a blood-cast, they are called " dark " or " opaque " 
granular casts. (Fig. 101, b) 3. Waxy casts appear to the eye to be 
more solid in structure than the hyaline casts ; they also appear more 
cylindrical in form, are more or less yellow in color, and are apt to be 
larger than hyaline casts. (Fig. 100, b, c.) 4. Fatty casts are hyaline 
or faintly granular casts on which are deposited in spots minute oil- 
drops. These are sometimes called " oil-casts " if the oil-drops are 
very abundant. (Fig. 102, a.) 5. Blood-casts are either made up of 
a mass of blood-cells pressed together into a cylindrical shape, or, more 



656 



SPECIAL DIAGNOSIS. 



frequently, a hyaline cast is studded with blood-cells. (Fig. 102, b, c.) 
6. Epithelial casts seem sometimes to be composed entirely of epithelial 
cells closely packed together. Such casts are relatively rare, and very 
beautiful. Ordinarily, just as in the case of blood-casts, an epithelial 



Fig. 103. Fig. 104. 




Cylindroids. (Dr. Alfred Stengel.) Spermatozoa. (Roberts.) 



cast consists of a hyaline cast more or less covered with renal epithelium. 
(Fig. 101, a.) 7. Dr. George Johnson has described casts composed of 
pus corpuscles. In two cases in which they were found in the urine 
the patients were found at autopsy to have multiple abscesses of the 



Fig. 105. 




Human semen, a, Spermatozoa ; b, cylindrical epithelium ; c, bodies enclosing lecithin 
granules ; d, squamous epithelium from the urethra ; d', testicle cells ; e, amyloid corpuscles ; 
/, spermatic crystals ; g, hyaline globules. (Von Jaksch.) 

kidney. 8. Cylindroids are very common. In general appearances 
they resemble hyaline casts ; but they are apt to be much longer, to be 
bent, twisted, or split, and to have, on close examination, a striated or 
finely ribbed appearance. Moreover, the diameter of the cast frequently 
varies greatly at different points, sometimes it appears constricted in 
several places, and in other cases one end tapers off into a thread. Often 
they consist of fine, narrow ribbon-like threads. (Fig. 103.) 



DISEASES OF THE KIDNEYS. 



657 



Spermatozoa. Spermatozoa are easily recognized by their tadpole 
shape and by the vibratile motion of their long delicate tails. They 
are found in the urine of both sexes after sexual intercourse. (Fig. 104.) 



Fig. 106. 




Vaginal epithelium in the urine. (Roberts.) 



Many continent men have occasionally nocturnal emissions, accom- 
panied by erections and erotic sensations. These cannot be \ looked 
upon as abnormal, and they are compatible with robust health. J^There 



Fig. 107. 




a a', Pavement epithelium from urinary sediment ; b b' b", bladder epithelium ; c & c" c" f , renal 
epithelium ; d d', fatty degenerated renal epithelium ; e, h, bladder epithelium. (Von Jaksch.) 

are other persons, neurotic, anaemic, and generally constipated in habit, 
who have emissions at night two or three times a week, of which they 
are unconscious until after they wake and find themselves wet. Semen 
may also be lost during micturition and defalcation, especially when much 
straining is required. Such a condition (spermatorrhoea) is abnormal. 
It is due to general nervous and muscular relaxation, associated with 

42 



658 SPECIAL DIAGNOSIS. 

nervous dyspepsia and ansemia, and aggravated by sedentary life, con- 
stipation, and the reading of salacious literature or the cultivation of 



Fig. 10S 




Renal epithelium, a, Natural appearance, b, Atrophied and disintegrated renal cells, 
c, Renal cells in a state of fatty degeneration. (Roberts.) 

erotic thoughts. In young men it sometimes follows habits of mastur- 
bation, which have been broken up but have left behind a hypersesthetic 



Fig. 109. 




Epithelial cells from the bladder, ureter, and pelvis of the kidney. (Roberts.) 

condition of the prostatic portiou of the urethra, with or without 
dilatation of the orifices of the ejaculatory ducts; or a stricture of 
gonorrhoea! origin may be its cause. Students and overworked and 



DISEASES OF THE KIDNEYS. 



659 



overstrained business and professional men are the ones most frequently 
affected. 

However caused, the condition is apt to beget a most distressing 
state of despondency, in which the patient imagines all possible ills and 
is liable to drift into an hysterical, melancholic, even suicidal frame of 
mind, and so falls a victim to quacks. 

Epithelium. Epithelium from the kidney, bladder, and genito- 
urinary passages occurs in the urine. Epithelial deposits in male urine 
are very scanty, unless there is some disease of kidney or bladder, or a 
catarrhal condition of the prostatic urethra, such as is left from an old 
gonorrhoea. On the contrary, considerable epithelium may be normally 
present in the urine of women, being derived principally from the vagina 
and bladder. 

Vaginal epithelium consists of large flat pavement cells, and is 
readily distinguished. 

The type of epithelium of the kidney, kidney pelvis, ureter, and 
bladder is the same, and it is not possible to distinguish with certainty 
the cells which come from each. If the cells are scanty, Von Jaksch 
thinks this fact to be in favor of an origin from the ureter. He has 
found them in moderate quantity and superimposed upon one another. 

Renal cells resemble closely the oval or polygonal cells from the 
deeper layers of the bladder, but they have a relatively larger nucleus. 

Fat. In addition to the presence of oil-drops in association with 
fatty degeneration of the kidney and its epithelium, oil is found occa- 
sionally in the urine of those who are taking cod -liver oil, and in cal- 
culous disease of the pancreas. Tyson suggests that it may come from 
cystic cheesy degeneration of the kidney. 

Fig. 110. 
Vibriones in urine. (Roberts.) 

Lipuma. In chronic nephritis, in phosphorus poisoning, and in 
diabetes mellitus fat is found, as well as in chyluria. The urine is 
turbid, but clears when agitated with ether. The fat may be separated 
by a sedimentator, and can be recognized by its refracting properties. 

Chyluria. This is a more or less milky condition of the urine, due 
to the presence of fat, which probably gains entrance to some part of 
the urinary tract by rupture of the lymphatic vessels. A case has 
been reported by Saundby in which a young unmarried girl, having been 
pregnant, compressed her abdomen so much in order to conceal her 
condition that oedema of the legs, thighs, vulva, and lower part of the 
abdomen resulted. After her confinement the urine became milky, and 
remained so for many days. It contained fatty matters, cholesterin, 
but no albumin or sugar. 

Fat and albumin appear at the same time in some diseases. They 



660 



SPECIAL DIAGNOSIS. 



recur at long intervals. Red and white corpuscles are also found in 
small amounts. The urine coagulates on standing, or gelatinizes. It is 
due to the invasion of the urinary tract by the filaria sanguinis hominis, 
the embryo of which is found in the urine. 

Parasitic chyluria is due to the filaria sanguinis hominis, whose 
embryos obstruct the lymphatics. 

Entozoa. The most common is the echinococcus or hydatid. When 
this infects the kidney or uriuary vessels hooklets and even cysts have 
been passed in the urine. The disease is, of course, extremely rare in 
this country. 

The filaria sanguinis hominis, which causes parasitic chyluria, is occa- 
sionally found in the urine. (See Filaria.) 

The Bilharzia hcematobia sometimes lodges in the urinary tract and 
causes hseniaturia. It is peculiar to Egypt. 

Intestinal worms may creep into the bladder through fistulous or 
other openings, and be discharged through the urethra. 



Fig. 111. 




Various forms of uric acid crystals. (Finlayson.) 



Micro-organisms. Normal urine contains no micro-organisms at 
the time it is voided. As the result of exposure to the air, however, they 
may develop in great abundance. The non-pathogenic organisms found 
are classed as mould fungi (hyphomycetes), yeast fungi (blastomycetes), 
and fission fungi (schizomycetes). 

Mould fungi, according to Von Jaksch, are rarely found in foul 
normal urine. Yeast fungi are also rare in normal urine. Fission 
fungi are found in urine undergoing ammoniacal decomposition. 

Sarcinse, usually smaller than those of the stomach, are occasionally 
met with — especially, according to Roberts, when there is some disorder 
of the urinary organs, renal pains, painful micturition, cystitis, etc. 

Under the name baderiuria Roberts and others have described cases 
in which the urine at the time of being voided contained bacteria. He 
makes four groups : (1) Cases in which the presence of bacteria is asso- 



DISEASES OF THE KIDNEYS. 



661 



ciated with incipient putrefactive changes in the urine ; (2) cases associ- 
ated with ammoniacal fermentation of the urine ; (3) cases in which the 
common forms of bacteria are present without decomposition of the 
urine ; and (4) cases in which micrococcus chains are voided in the 
urine. 

Fig. 112. 




Amorphous urate deposit. (Roberts.) 



The pathogenic organisms which are more or less closely associated 
with infectious diseases, septic processes, and tuberculosis, are found at 
times in the urine, and can be demonstrated by the proper staining 
methods. 



Fig. 11c 




Urate of soda. 
a a. From a gouty concretion ; b b. 
Artificially prepared by adding liq. 
sodse to the amorphous urate deposit. 
(Roberts.) 



Fig. 114. 




Hedgehog crystals of urate ot 
soda, spontaneously deposited 
from the urine of a child. 

(Roberts.) 



Moebid Geowths. The urine very rarely contains the elements of 
morbid growths. Von Jaksch says he never has found them in any way 
reliable in the case of tumors of the kidney. The detection of cancer 
cells or pigmented cells, such as occur in melanotic cancers, may confirm 
the diagnosis, if the clinical symptoms point to cancer. Tumor 
elements are most likely to be found in ulcerating tumor of the 
bladder. 



662 



SPECIAL DIAGNOSIS. 



Unorganized Sediments. Uric Acid. Uric acid is present in 
small quantities (eight to ten grains a day) in normal urine. It is 
increased in febrile and wasting diseases, such as phthisis ; in diseases 
of the liver and spleen (leukaemia), and in malarial fever, diabetes, 
scurvy, rhachitis, and following an attack of gout. Excessive use of 
milk is said sometimes to increase it. Its excretion is also increased by 
certain drugs — colchicum, corrosive sublimate, and euonymin. 



Fig. 115. - 




Urate of ammonia spontaneously deposited. 
a. Spheres and globular masses ; b. Dumb-bells, crosses, rosettes. (Roberts.) 

It is diminished in anaemia, chlorosis, during a paroxysm of gout ; 
in chronic nephritis ; by certain drugs — large doses of quinine (Ranke), 
caffein, sodium chloride and sodium carbonate, lithia, and iodide of 
potash. 

Fig. 116. 




Various forms of triple phosphates. (Finlaysox.) 



According to Roberts, a deposit of uric acid occurring some twelve to 
twenty hours after the urine has been passed has no pathological signifi- 
cance. If the deposit occurs within three or four hours after it has 
been passed it is certainly not natural : it is frequently observed in con- 
valescence from febrile complaints, especially articular rheumatism ; 
also in the middle periods of chronic Bright's disease, in chorea, in 
certain types of diabetes, and in enlargement of the spleen. If, how- 
ever, the uric acid is precipitated before the urine cools, or immediately 
afterward, there is a liability that the same precipitation may occur 
within some part of the urinary passages, and so form a calculus. 



DISEASES OF THE KIDNEYS. 



663 



Urates. Amorphous urates appear uuder the microscope as opaque 
granular particles, which dissolve upon heating, and respond to the 
murexid test. The deposit is more or less dense, and is sometimes 
arranged so as to resemble granular casts. (Fig. 112.) 

Urate of Soda appears as spherules or globules from which project 
short spines, either straight or curved. It occurs most frequently in 
concentrated acid urines, such as are passed by children with acute 
febrile diseases. (Figs. 113 and 114.) 

Urate of Ammonia resembles the urate of soda, except that it has 
no spines. It is associated frequently with phosphatic deposits, and is 
precipitated from alkaline urines. Sometimes it appears in the shape 
of dumb-bells. (Fig. 115.) 

Phosphates. Phosphates appear in the urine as ammonio-magnesium 
phosphate, and as the crystalline and amorphous phosphate of lime. 



Fig. 117. 




Crystalline phosphates. (Finlayson ) 



They are precipitated in alkaline or faintly acid urines, which produce 
a cloud upon being heated ; the cloud is distinguished from albumin, as 
already pointed out, by disappearing when the urine is acidulated with 
acetic or nitric acid. Ammonio-magnesium phosphate is easily recognized 
by its rhombic prisms — " coffin-lid " shape. Other shapes are produced 
by modification of the primary one, chiefly by bevelling of the edges 
and hollowing out of the sides. These crystals are usually large, and 
are frequently found together with amorphous phosphates, bladder 
epithelium, and pus, in cases of cystitis. 

Amorphous phosphate of lime consists of fine granular particles, much 
resembling amorphous urates, but distinguished from them by not dis- 
appearing upon the application of heat, but instantly dissolving when 
the urine is acidulated. 

Crystalline phosphate of lime is a rare deposit. It is found as rods 
or needles, and occasionally grouped together in the form of stars, 
sheaves, or bundles. 

According to Roberts, this deposit in quantity is an accompaniment 
of some grave disorder. He has found the stellar phosphates in cancer 
of the pylorus, once in phthisis, and more than once in patients 



664 



SPECIAL DIAGNOSIS. 



exhausted by obstinate chronic rheumatism. It may, however, occur 
in health, when the urine is rich iu lime and its acidity greatly re- 
duced. 

Fig. 118. 




Oxalate of lime, a, b, c, Octahedra in various positions ; d, pyramids ; 
e, pyramids with intervening square bases. (Roberts.) 

Oxalate of Lime. Oxalate of lime occurs in the form of small octa- 
hedral crystals, or more rarely as dumb-bells, and in the form of ovals 
or disks. It is precipitated, almost alwavs, from acid urines. (Figs. 
118 and 119.) 



Fig. 119. 




Less common forms of oxalate of lime crystals. (Finlayson.) 



According to Beneke, oxaluria has its proximate cause in an impeded 
metamorphosis, an insufficient activity of that stage which changes oxalic 
acid into carbonic acid. 

When oxalates are constantly found in the urine a condition of pro- 
found hypochondriasis is found to exist, but it has no necessary relation 
to the oxaluria. 



DISEASES OF THE KIDNEYS. 



665 



Oxaluma. An increase of oxalate in the orine is found in dia- 
betes, especially when there is diminution in the amount of sugar. It 
is in excess in certain forms of indigestion. Its constant passage may 
be attended by pains in the back and loins. Flatulent and nervous 
dyspepsia usually accompany the increase, and, with neurasthenia, are 
common. 



Fig. 120. 




Crystals of leucin (different forms). (Crystals of creatinin chloride of zinc resemble the leucin 
crystals depicted at a.) The crystals figured toward the right consist of comparatively impure 
leucin. (From Charles : Chemistry.) 



Fig. 121. 




Tyrosin crystals. (From Charles : Ibid.) 



Cyslin. Cystin occurs in the form of hexagonal prisms, either as 
irregular masses, or superimposed one upon another, so as to form trun- 
cated pyramids. It is a very rare sediment, but appears to be most 
common in children and young male adults. Several members of the 
same family have been known to pass it. Its chief clinical significance 
arises from the fact that it is rarely the basis of calculi. 

Leucin and Tyrosin. Leucin and tyrosin are generally described 
together, though the former is not spontaneously deposited from urine. 
It appears in the form of spheres which refract light strongly and have 
a radiating arrangement. (Fig. 120.) 

Tyrosin has been found as a sediment, of a light greenish -yellow 
color, in typhoid fever and acute yellow atrophy of the liver. It ap- 
pears in the form of tolerably long needle-like crystals, or as bundles 
and sheaves. Frerichs attaches great importance to leucin and tyrosin 
in the diagnosis of acute yellow atrophy of the liver. (Fig. 121.) 

Cholesterin. This occurs at times in fatty degeneration of the 



666 



SPECIAL DIAGNOSIS. 



kidneys, jaundice, chyluria, diabetes, and, according to Pohl, in the 
urine of epileptics treated with bromide of potash. (Fig. 122.) 



Fig. 122. 




Crystals of cholesterin. (From Charles : Ibid.) 



Melanuria. Melanin is held in solution or suspended in small 
granules. The urine is dark in color, but blackens intensely when 
sulphuric acid or tincture of chloride of iron is added to it. A con- 
centrated solution of perchloride of iron serves to detect the presence 
of the substance. A few drops added to the urine turn it gray. If a 
few drops more are added, the phosphates are precipitated aloug with 
the coloring matter. Both are dissolved by an excess of the iron solu- 
tion. Melanin is usually found in cases of melanotic carcinoma. 

Objective Symptoms due to Impairment of the Function 
of the Kidney. Uraemia. 

To this class of symptoms belong the various manifestations of 
uraemia. Diseased kidneys do not eliminate the products of tissue 
waste which are poisouous materials. The toxic matter is retained 
within the blood, and produces a toxaemia, which may be acute or 
chronic. In acute urcemia the manifestations develop suddenly, and 
continue but a short period of time, with alarming active symptoms 
until death or recovery. In chronic urcemia the onset is gradual. The 
manifestations may be limited to one or two conditions, as headache or 
morning nausea, or they may include the more pronounced forms of 
uraemia. 

Cerebral Symptoms. 1 . Headache. The pain is situated in the 
occipital region, and may extend down the neck. It is severe and 
of a bursting character. It may be associated with giddiness. In 
both acute and chronic nephritis it is often the first manifestation. It 
may be associated with eye symptoms. It may be present on waking, 
and continue only through the morning hours. In acute uraemia it 
persists throughout the attack. Numbness and tingling of the fingers 
are often complained of at the same time. 

2. Delirium. The delirium may be mild. This is usually the case 
if the typhoid state or a subnormal temperature prevails. It is some- 
times attended by delusions. There is subsultus often, and picking at 
the bed-clothing. The delirium may amount to true mania, and may 
be active and the patient exhibit other maniacal symptoms. On the 
other hand, the patient may be noisy, restless and sleepless. Melancholia 
and delusive insanity may develop after the violent nervous symptoms 
of uraemia pass off. 



DISEASES OF THE KIDNEYS. 



667 



3. Convulsions. A convulsion may be the first indication of disease 
of the kidneys, or it may succeed a few days of persistent headache, or 
follow an attack of ursemic vomiting. The convulsion resembles 
epilepsy, and hence is known as an epileptiform convulsion. If recur- 
ring in rapid succession the interval is occupied by delirium or coma. 
If infrequent, the patient's mind may be clear in the intervals. Some- 
times a focal or Jacksonian epilepsy occurs instead of the true epilepti- 
form convulsion. The temperature is usually elevated. In worn-out 
subjects, or those who have had exhaustive diarrhoea or other debilitating 
cause, the temperature may be subnormal. A temporary blindness 
often follows the convulsion (urcemic amaurosis). Ursemic deafness may 
occur. 

4. Coma. After the convulsion the mind may be restored, or the 
patient lapse into stupor followed by complete coma. Coma may 
develop without convulsions, or immediately succeed a general con- 
vulsion. Headache or eye symptoms may precede the coma. The 
patient in some instances lapses into a typhoid state in which the 
tongue is heavily furred and the breath very offensive. Unless the 
coma is very profound there is usually some twitching of the muscles 
of the hands and face. 

5. Local Palsies. Dercum was among the first to call attention to 
the occurrence of monoplegia or hsemiplegia in the course of nephritis, 
which is distinctly of renal origin. The cases resemble central cerebral 
disease. The nature of the palsy is inferred by the results of the 
examination of the urine and the condition of the heart and arteries. 
Palsy develops suddenly, or may occur after a convulsion. 

6. Cramps in the muscles of the calves, particularly at night, are of 
common occurrence, and should always lead to an examination of the 
urine. 

7. Pruritus, local or general, is another nervous symptom which may 
be of ursemic origin. 

8. Pain in the upper abdomen, or particularly in the median line, is 
a frequent precursor of more severe ursemic symptoms. It is of 
ursemic origin itself. It may be seated in either of the upper quadrants, 
and from thence extend to the lower portion of the abdomen. 

Uremic Dyspncea. Modifications of the breathing often accompany 
symptoms of uraemia. The dyspnoea may be constant. It may occur 
in paroxysms, or both types may alternate. A common type in the 
uraemia of chronic nephritis is the Cheyne-Stokes breathing. Par- 
oxysmal dyspnoea usually occurs at night, and resembles asthma in 
every respect. Cheyne-Stokes breathing continues, even through the 
period of coma, although not necessarily associated with it (see page 282). 

Gastro-Intestinal Symptoms or Uraemia. Several forms are 
seen. 1. Loss of appetite is common. It is attended with absolute 
distaste for food after a small portion is taken. 2. Nausea, which may 
be continuous, or more frequently is limited to the early morning. 3. 
Vomiting may be paroxysmal, occurring chiefly in the early morning, 
or it may be sudden in onset, uncontrollable, and continue until nervous 
symptoms of uraemia develop. Urea is found in the vomit. The 
matter ejected is profuse, of a low specifie gravity and at first acid in 



668 



SPECIAL DIAGNOSIS. 



reaction. If chronic, it may become alkaline. The odor is often 
sufficient to cause its recognition. 4. Constipation is generally the rule 
in the course of chronic Bright's disease. 5. Diarrhoea. One of the 
manifestations of uraemia is the occurrence of sudden, profuse, serous 
purging. This may be so extreme as to cause collapse, or may usher 
in coma and convulsions. 6. Hiccough, although a muscular affection, 
is usually associated with gastric disturbances. 

Acetonemia. Acetonemia is a toxaemia which develops in the 
terminal stages of diabetes. It is due to an accumulation of acetone 
in the blood. It is also called diabetic coma. It develops acutely. A 
sudden onset is attended by sharp pain in the stomach with nausea, and 
frequently the occurrence of vomiting. At the same time there is 
severe dyspnoea. The breathing is irregular, and of a panting character. 
The patient is required to sit up in bed on account of the air-hunger. 
Restlessness begins at once. Delirium develops within the first hour. 
In a few hours coma sets in. The temperature is subnormal ; the 
pulse irregular, and soon becomes weak and thready. The odor of 
acetone is detected on the breath. 

Cardio -Vascular Symptoms. The symptoms are the effects of the 
retention of morbid products. First, the heart and bloodvessels. The 
poison which is not excreted circulates throughout the system. One of 
its effects is irritation of the vasomotor nerves of the bloodvessels. 
Excitation of these nerves causes peripheral contraction of the smaller 
vessels. At once obstruction to the flow of blood is created, so that, on 
account of the contraction, hypertrophy of the heart rapidly ensues. 
The first prominent symptom, therefore, is due to changes in the heart 
muscle. 

Hypertrophy of the Heart. Of these the most pronounced is 
hypertrophy. The persistent spasm of the peripheral vessels causes 
increased arterial tension. The blood-pressure is raised and causes 
increased accentuation of the aortic second sound. High tension in the 
artery is recognized by the peculiar character of the pulse and by means 
of the sphygmograph. 

Dilatation of the Heart. Unfortunately, it is not always that 
hypertrophy of the heart can be kept up. If it fails, we then have a 
second condition of the heart which is frequently found in renal in- 
flammations ; it is dilatation. This condition of the heart muscle is 
predisposed to by the state of the coronary arteries. The previously 
mentioned arterial tension favors the development of chronic endar- 
teritis with general atheroma. The coronary arteries take part in this 
process. The endarteritis hinders cardiac nutrition, dilatation of the 
heart muscle follows, and later comes the development of two other 
conditions, atrophy and myocarditis. The above conditions are secondary 
to renal disease. 

Here may be mentioned other relations of the heart and kidneys. 
a. We have renal disease following forms of cardiac disease. In dilata- 
tion of the heart passive congestion of the particular organ takes place. 
The kidney very quickly becomes the seat of such congestion. In the 
course of simple dilatation, or of valvular heart disease, the secondary 



DISEASES OF THE KIDNEYS. 



669 



dilatation, passive congestion, and chronic inflammation develop slowly. 
Embolic process may also occur. b. Renal disease and cardiac disease 
may develop at the same time out of a common cause, as alcoholism, 
gout, or endarteritis. 

In addition to high arterial tension and accentuation of the aortic second 
sound, the objective symptoms of atheroma of the aorta and arteries is 
present with the chronic inflammations of the kidney. These vascular 
changes need not be again rehearsed. (See Endarteritis.) 

It is important, however, to bear in mind the proposition which in- 
dicates their frequent association, and also that in all instances of arterial 
disease the condition of the urine must be inquired into. It need not 
be said that symptoms due to rupture of the bloodvessels, particularly 
in the brain, or to aneurism, may necessarily be present in the course 
of renal inflammation. 

Hemorrhages. The arteries are very liable to rupture, causing 
epistaxis, retinal hemorrhage, hemorrhages from the bowels and lungs, 
and hemorrhages underneath the skin. Frequent hemorrhages in large 
amount from any portion of the body should call attention to the con- 
dition of the urine. 

Ophthalmoscopic Changes. Examination of the eye-ground 
should always be made, although attention is often directed to the eye 
by the complaints of the patient. The changes may occur in the acute 
or chronic forms of nephritis, although they are more common in the 
latter. 1. A diffuse slight opacity and swelling of the retina, due to 
oedema. 2. White spots or patches of various sizes, for the most part 
the result of degenerative processes. 3. Hemorrhages. 4 t Inflamma- 
tion of the intra- ocular end of the optic nerve. 5. Atrophy of the 
retina and nerve may sometimes result from and succeed the inflamma- 
tory changes. These changes may affect one eye only (Gowers). It 
must not be forgotten that temporary blindness may occur independent 
of retinitis. 

Dropsy. Dropsy may occur in all forms of nephritis. It is most 
common in acute varieties, but it is also present in chronic diffused 
nephritis with exudation. Renal dropsy usually begins in the face. It 
may develop suddenly in acute forms. In the marked forms oedema of 
the eyelids may continue for a long time. From local oedema all varia- 
tions may be found to the point of extreme anasarca. The serous 
cavities are often filled. The oedema is usually associated with a 
diminished amount of urine. Its improvement is attended by increased 
diuresis. Dropsy, in chronic disease, is usually due to dilatation of the 
heart (see page 92). 

The Cutaneous Symptoms, and Appearance of the Face. 
In inflammatory affections of the kidney the appearance of the skin and 
expression of the face are often characteristic, and point at once to an 
examination of the urine. The face is pallid, and of an ivory white- 
ness. In the chronic forms the pallor gives way to an ashen-gray or a 
sallow complexion. In chronic nephritis the skin becomes dry and 
harsh, and rarely is covered with a powdery substance, giving it the 
appearance of frost on the skin. The powdery substance is due to 
urea. 



670 



SPECIAL DIAGNOSIS. 



Petechia?. In the later stages of chronic inflammatory affections 
hemorrhages under the skin and in the mucous membranes are seen. 

Anaemia. Anaemia is a frequent symptom in all forms of nephritis ; 
it is usually marked. It is associated with the peculiar pallor just 
described and attended by all the symptoms of anaemia. The recogni- 
tion of the anaemia is only possible by examination of the urine and the 
blood. 

General Symptoms. The cause of renal disease, as far as symp- 
toms pointing to the kidneys are concerned, is often latent. Instead of 
renal symptoms, a generally depraved state of the system is seen, with 
emaciation and weakness. Lassitude without cause demands an examina- 
tion of the urine. 

Respiratory Symptoms. In addition to uraemic respiratory phe- 
nomena, the occurrence of pulmonary complications may be the first 
indication that the condition of the urine should be inquired into. 
Bronchitis, pneumonia, and pleurisy are common complications. 

Gastro-Intestinal Symptoms. Uraemic symptoms have been 
referred to. Fermentative dyspepsia, gastralgia, and constipation are 
of common occurrence. 

Congestions of the Kidney. 

Congestions of the kidney are acute and chronic, and depend upon 
changes in the circulation, whereby blood accumulates in the kidney. 

Acute Congestion of the kidney is caused by the action of irritant 
poisons ; follows surgical operations, particularly if prolonged, and may 
follow extirpation of one kidney. Kidneys that are the seat of disease 
are liable to become the seat of active congestion. 

Symptoms. The urine is diminished in amount, or may be suppressed 
entirely. Only a small amount is passed at frequent intervals, or it can 
be secured by the catheter alone. Albumin is present in considerable 
amount, and blood and epithelial casts are numerous. Death may 
take place with symptoms of uraemia. 

Chronic Congestion of the Kidney. It is also called passive conges- 
tion. This form of congestion is usually a part of general venous stasis 
due to disease of the heart or lungs, as valvular disease of the heart with 
secondary dilatation or pulmonary emphysema. It is quite common. 

Symptoms. The urine is diminished in amount ; dark in color ; of 
high specific gravity, ranging from 1020 to 1030. Uric acid and urates 
are increased. Urea to the amount of from 10 to 12 grains to the 
ounce is passed in twenty-four hours. At first there is no further 
change, but later, albumin appears in small amounts in an intermittent 
manner. Later it is constant and increased in amount. Hyaline casts 
are found in the urine, and a few red blood-cells. 

The condition is recognized by its association with congestion in other 
organs; by the diminution in the amount of urine, its high specific 
gravity, and excess of uric acid and urates. This form of congestion is 
serious, because it leads to chronic nephritis. The presence of the latter 
is recognized by the usual changes in the urine. 



DISEASES OF THE KIDNEYS. 



67] 



Inflammations of the Kidney. 

The inflammations of the kidney are divided in accordance with the 
activity of the process and the degree of exudation or cell-proliferation 
that attends the inflammation. We, therefore, have the following 
varieties : 

Acute exudative nephritis (acute Bright's disease). 

Acute productive or diffuse nephritis (acute Bright's disease). 

Chronic productive or diffuse nephritis with exudation (chronic 
tubular nephritis). 

Chronic productive or diffuse nephritis without exudation (chronic 
interstitial nephritis). 

Suppurative nephritis. 

Tubercular nephritis. 

Acute Exudative Nephritis or Glomerulo-Nephritis. In 
this form of nephritis there is congestion, exudation of plasma, transu- 
dation of red and white blood-cells, and changes in the epithelium. 

Causes. It may occur without definite cause, save exposure to cold, 
and at times even without such history. It occurs in most of the in- 
fectious diseases. It is of common occurrence after scarlet fever, and in 
the course of pregnancy, and in septicaemia. It occurs in diphtheria, 
erysipelas, and pneumonia frequently. It is the expression of a pecu- 
liar type of typhoid fever. It may complicate dysentery and acute 
tuberculosis. It forms one of the modes of termination of diabetes. 

Symptoms. The course of the disease may be mild, presenting only 
changes in the urine, or there may be in addition to decided changes in 
the character of the urine, local and general symptoms. 

In mild cases the urine is diminished in amount ; micturition is 
frequent; the color of the urine is increased, and the specific gravity is 
usually high. A small amount of albumin is found, and a few epithe- 
lial and blood casts, and sometimes blood. At the termination of the 
disease the casts are hyaline. 

In severe cases the disease is ushered in by chill, attended and fol- 
lowed by pain in the loins, with fever, headache, and much restlessness. 

The urine may be passed more frequently than usual, but in small 
amounts ; or micturition may diminish in frequency or cease entirely. Ex- 
amination of the urine reveals the characteristic changes. The quantity of 
the urine is lessened ; the specific gravity is normal or increased. There 
is a large amount of albumin, and an abundance of hyaline, granular, 
epithelial, and blood casts. Free white and red blood-cells, and epi- 
thelium from the pelvis and tubules are found. 

The fever continues; the pain in the loins is sometimes very severe, 
and may be taken for lumbago, unless an examination of the urine is 
made. Within the first forty-eight hours the characteristic symptoms 
that follow the chill and that attend the urinary changes are headache, 
sleeplessness, more or less stupor, muscular tioitchings, or general con- 
vulsions. Eye symptoms may be complained of. Instead of cerebral 
symptoms, dyspnoea may be marked. With both, nausea and vomiting 
are of common occurrence. The heart's action is increased in force and 
frequency. The left ventricle rapidly becomes hypertrophied. The 



672 



SPECIAL DIAGNOSIS. 



aortic second sound is accentuated. The pulse is hard and exhibits the 
characteristic features of high tension. From the onset of the first 
symptom, or within the first week, two other striking phenomena arise. 
They are, first, the occurrence of dropsy ; second, the occurrence of 
ancemia. 

Dropsy or oedema is one of the most constant symptoms. It appears 
first in the face, especially the eyelids. It may be limited to this 
region. It is worse in the mornings. From the face, in bad cases, it 
extends to the lower extremities and to the scrotum, and from thence 
all over the body. Anasarca is the name applied to the general dropsy; 
the connective tissue is infiltrated with serum. It is recognized by the 
pallor of the swollen surface ; the pitting on pressure ; the absence of 
heat and of pain. (See page 92.) 

Effusion may take place into the serous cavities, either the pleura, 
pericardium, or peritoneum, causing the symptoms due to effusion. 
In some instances there is oedema of the mucous membranes, as the 
conjunctiva, the soft palate, and the glottis. 

Dyspnoea may be a pronounced symptom, due either to uraemia 
(ursemic asthma) or oedema of the glottis, effusions into the pleura, or to 
bronchitis. If dilatation of the heart occurs, dyspnoea may arise, due 
to that or to the secondary oedema of the lungs. 

With or without the occurrence of nausea or vomiting there is always 
loss of appetite, and usually constipation. 

The fever is usually moderate and irregular in type. Prostration is 
common ; often there is emaciation. Symptoms of urwmia may occur 
at any time. 

Exudative nephritis with excessive pus is of sudden onset, charac- 
terized by high fever and extreme prostration. There is rapid emacia- 
tion and the early development of the typhoid state. This is preceded by 
delirium, headache, and stupor, with great restlessness. There is but 
little, if any, dropsy. Large numbers of red and white blood-cells and 
the usual casts are found in the urine. There is not as much diminu- 
tion in the urine as is usually seen. The disease may arise without 
cause, or complicate scarlet fever or diphtheria. 

This form is very fatal, and resembles acute meningitis, from which it 
is diagnosticated by the change in the urine. 

Acute Productive or Diffused Nephritis. In this form 
there is an overgrowth of connective tissue and excessive growth of the 
capsule cells in the glomeruli in addition to the lesions of the first form. 
The whole kidney is not necessarily affected, but only portions at a 
time. Symptoms: The onset is sudden. The subjective symptoms 
previously described are present in a marked degree. Nervous symp- 
toms (uraemia) are most pronounced. Dropsy develops rapidly and to 
an extreme degree. There is rapid development of ancemia and loss of 
flesh. The remaining symptoms tally with those of the first affection. 

The urine is scanty, bloody, and of high specific gravity. The 
microscopical appearances are like those of acute exudative nephritis. 
If convalescence is established the urine becomes more abundant, with 
a corresponding fall in the specific gravity. The albumin and casts 
may appear for a time, but eventually disappear. 



DISEASES OF THE KIDNEYS. 



673 



Diagnosis. The diagnosis of acnte nephritis of either form is based 
upon the examination of the urine. ^Etiological associations are of value. 
The more pronounced cases follow scarlet fever or pregnancy. In the 
latter condition it usually advances slowly. There may be no symp- 
toms until the occurrence of uraemia or acute lung symptoms. In 
some instances the disease resembles typhoid fever. In cases in which 
the onset is sudden with early uraeniic symptoms it must not be mistaken 
for epilepsy, delirium, or mania. 

Chronic Productive or Diffused Nephritis with Exuda- 
tion. In chronic inflammations the formation of new tissue always 
takes place. They are divided, therefore, in accordance with the exudation. 
The exudation is from the vessels. Causes: This form usually follows 
acute productive nephritis and chronic congestions or degenerations of the 
kidney. It develops in the course of syphilis, tuberculosis, endocarditis, 
disease of the bones, and prolonged suppuration. Frequent exposure 
to cold and wet, a residence in damp dwellings, and the alcoholic habit 
are causal conditions. It usually occurs in middle life, more frequently 
in men. When it occurs as a primary disease it is usually found in young 
adults. Symptoms : The disease develops slowly. General symptoms 
may first be observed. Dropsy may develop at first and continue 
throughout the disease, or recur at long intervals. The appearance of 
the patient is striking. The skin is of a peculiar pallor and pasty in 
appearance. The sclerotics are very white. The ancemia which gives 
rise to the pallor may be very profound and often be typical of that 
seen in the pernicious form of anaemia. The anaemia is due to dimi- 
nution in the haemoglobin and reduction in the number of red blood- 
cells. 

Headache and sleeplessness are common symptoms. Pronounced 
acute uraemia does not often occur. Chronic uraemia may prove fatal 
by the patients lapsing into a typhoid state in which delirium alternates 
with stupor. 

The urine is variable in quantity and character. It must not be for- 
gotten that the course of the disease and the urinary symptoms are often 
quite variable in chronic nephritis. The urine may be normal in amount, 
but during the exacerbations it is scanty or suppressed. The specific 
gravity and the amount of urea lessen. In the most rapid cases it varies 
between 1012 and 1020. In chronic cases it falls between 1001 and 1005. 
In the latter stages the amount of the urine and the specific gravity 
may both be increased. Albumin is present in large amounts. When 
the disease is most active, and the dropsy at its height, the quantity of 
albumin is very large. In the quiescent period of the disease the 
amount is lessened. Casts are abundant, both epithelial, bloody, fatty, 
and granular. 

Retinitis albuminuria is frequently developed in the course of the 
disease. 

Dyspnoea is a common symptom. The dyspnoea may be due to any 
one of the many causes previously described which promote this 
symptom in the course of nephritis. It is frequently limited to sudden 
attacks which develop in the night or early morning. There is often 
some bronchial catarrh. 

43 



674 



SPECIAL DIAGNOSIS. 



Nausea and vomiting are usual symptoms. The appetite is lost. 
Hypertrophy of the left ventricle takes place in all eases, except in 
those who had been previously weakened by other disease. The right 
ventricle is often hypertrophied also. The second aortic sound is 
accentuated, and the pulse is of high tension. Symptoms arise on account 
of the profound anwmia, such as headache and vertigo. 

The disease is characterized in its course by remissions and exacerba- 
tions. During the exacerbations any one of the prominent symptoms 
that occur in renal inflammations may be present. (Edema is the one 
symptom which occurs most frequently, and is likely to continue the 
longest. The disease lasts from three months to three years, and may 
pass into the second variety of chronic inflammation. 

Course of the Disease. Delafield has well outlined the course. The 
constant symptoms are anaemia, dropsy, and albuminuria. 1. The 
symptoms may be continuous and progressive in severity, death taking 
place at the end of one or two years, on account of dropsy or uraemia. 
2. The symptoms may continue for several months, and the patient 
finally improve. Recurrent attacks take place, the symptoms being 
more severe with each attack. In the intervals of the attacks there is 
a small amount of albumin. 3. The patient may apparently recover, 
but the urine continues to be of low specific gravity, and contains some 
albumin. A fatal attack of uraemia, or an apoplexy, or the onset of 
an acute disease, may cause an exacerbation of the renal symptoms. 
4. The symptoms in a mild degree may persist for years, the patient at 
the same time feeling comparatively well. 5. Spasmodic dyspnoea 
may be the first and only symptom for a long time. 

Chronic Productive or Diffused Nephritis without Exu- 
dation. This is the form of nephritis which is also called interstitial 
nephritis, granular kidney or cirrhosis of the kidney. 

The kidneys are diminished in size, the capsules adherent, and the 
surface roughened. There is an overgrowth of connective tissue with 
atrophy in the epithelium and the tubules, and dilatation of some of 
the tubes, forming cysts. 

Causes. This form of nephritis follows chronic congestion of the 
kidney, and is also caused by alcohol, lead, gout, syphilis, malaria, 
and by chronic endarteritis. The latter condition, as well as 
cirrhosis of the liver and pulmonary emphysema, frequently develop 
hand-in-hand with the nephritis. This form of nephritis is notably 
prevalent in several generations of different families, so that an heredi- 
tary history is often readily obtained. 

Symptoms. The onset of the disease usually occurs late in life, 
although well-defined cases may occur as early as the twenty-fifth year. 
The progress at first is very insidious, and the disease may have 
advanced to an extreme degree without the occurrence of a single 
symptom. Death, indeed, may be due to other causes, or a person in 
perfect health may suddenly manifest symptoms of uraemia, or be 
seized with apoplexy or other usual complication. 

The urine is increased in amount, clear in color, and of low specific 
gravity. The albumin is small in amount, or may be absent. Repeated 
examinations conducted over a considerable period of time, may disclose 



DISEASES OF THE KIDNEYS. 



675 



its presence. Hyaline casts are present in small numbers. In some 
examinations it may require a dozen or fifteen slides to be passed over 
before they are found. Sometimes there are a few red blood-cells, 
Rarely in the course of the disease the urine may be bloody at irregular 
periods, or actual hematuria may take place. With the exception of 
the state of the uriue the ouly symptom preseut may be loss of flesh 
and strength. At the same time the skiu becomes dry and harsh. 
(Edema, however, is not usually present unless there is dilatation of the 
heart. Special symptoms are due to uraemia, to changes in the heart 
and arteries, and to neuro-retinitis. 

The Heart. The left ventricle hypertrophies. The aortic second 
sound is accentuated. The arterial pulse is of high tension. The 
arteries become more prominent, and present all the signs of endarte- 
ritis. In the later stages, as nutrition fails, dilatation of the heart takes 
place with regurgitation at the mitral valve, and the development of a 
train of symptoms due to these changes. Among others we find 
general malaise, palpitation of the heart, dyspnoea, oedema, and visceral 
congestions. 

Urcemic Symptoms. These symptoms may occur at any time in the 
course of the disease. Headache is most common and constant. It 
may occur in the early morning only, or continue throughout the day. 
It may be continuous and cause sleeplessness. General neuralgic pains 
may be present instead of severe headache. Muscular twitchiugs or 
general convulsions may be other pronouuced symptoms, or, instead, 
delirium which may be mild or violent, stupor, and coma may come on. 
These symptoms may occur suddenly, or develop very gradually. In 
acute uraemia the above-mentioned cerebral symptoms occur, and at the 
same time there is peripheral spasm of the arteries, causing high arterial 
tension with elevation of the temperature. The fever may rise to 103® 
or 104°, but is usually about 102°, and is irregularly continuous. 
After the patient lapses into deep coma, if the attack is fatal, the 
tension of the pulse is lost, and it is increased in frequency and diminished 
in strength. In chronic uraemia the cerebral symptoms develop 
gradually. The temperature is likely to be subnormal. The pulse is 
rapid and feeble. 

Pulmonary symptoms due to uraemia are quite common. They may 
be the first expression of uraemia. This is seen in all forms of nephritis. 
The most marked symptom is dyspuoea, which is spasmodic and of 
short duration. The attacks may occur frequently, and are usually 
increased by exertion and aggravated by a recumbent posture. The 
shortness of breath may occur in the early morniug hours, or may con- 
tinue throughout the day. 

Gastro-intestinal Symptoms. Catarrhal gastritis almost always com- 
plicates nephritis. In addition, gastric symptoms due to uraemia, and 
hence to deficient action of the kidney, ensue. The most common is the 
occurrence of morning nausea or of morning vomiting ; the occurrence 
of spasmodic vomiting at irregular periods, or the occurrence of violent, 
acute vomiting which is followed in two or three days by other symp- 
toms of uraemia. The patients are usually constipated. When the 
disease is complicated with cirrhosis of the liver intestinal catarrh is 



676 



SPECIAL DIAGNOSIS. 



common, and intestinal ulceration with consequent diarrhoea is fre- 
quently found. The onset of uraemia may be characterized by violent 
aud profuse serous purging, which of itself may cause collapse and 
death. 

Neuro-retinitis is a frequent complication of nephritis, aud may 
advance more rapidly than other complications, so that dimness of 
vision, blindness, or other eye symptoms may cause the patient to con- 
sult an oculist before attention is called to the condition of the kidneys. 
The occurrence of this complication points at once to the necessity of an 
examination of the urine. 

It is common in the course of an interstitial nephritis to have occur 
accidents due to the condition of the arteries that accompany this dis- 
ease. On account of the atheroma, aided by the hypertrophied heart, 
rupture of the vessels frequently takes place. Apoplexy is, therefore, 
of common occurrence, and hemorrhage into other organs sometimes 
occurs. 

There is always a tendency to chronic inflammations of the mucous 
membranes and to acute inflammations of serous membranes in the 
course of chronic diffused nephritis. It is necessary, therefore, when 
local inflammations of this character are present, to make thorough and 
repeated examinations of the urine, especially in patients over forty 
with a history of one of the causal factors previously mentioned as 
operative in the individual. 

In addition to the pulmonary symptoms of uraemia, symptoms refer- 
able to the lungs are common from other causes. The symptoms may 
be due to an intercurrent bronchitis, pneumonia, or pleurisy. Chronic 
bronchitis or oedema of the lungs may be present on account of dilatation 
of the right heart. The chief pulmonary symptoms that point to these 
conditions are dyspnoea and cough. 

Course of the Disease. Several forms of interstitial nephritis are 
observed. In the latent form the disease may have advanced to an 
extreme degree, and death takes place from an intercurrent disease or 
accident, no symptoms of renal disease having been present during life. 
On the other hand, palpitation of the heart may be the only symptom 
complained of, and the observer finds a hard pulse, general atheroma, 
and hypertrophy of the left ventricle with accentuation of the second 
sound. Apart from this they may enjoy very good health. Their 
danger lies in the occurrence of pneumonia or inflammation of a serous 
membrane. Often the local inflammatory symptoms are slight or 
masked by the symptoms of renal disease, which develop rapidly. 

In another group of cases some special symptom only may be com- 
plained of. In some instances it may be gastric catarrh, in others eye 
symptoms alone may be present, while in others hemicrania or other 
forms of headache are observed. With the headache there is usually 
vomiting. Again, we may see constant neuralgias on the one hand, or 
persistent muscular rheumatism to be the only symptom. Nose-bleed 
is a symptom which may be the only indication of chronic nephritis, 
particularly if the epistaxis occurs frequently. 

In other cases the course is not latent, but characterized by a series 
of attacks at varying intervals.' 



DISEASES OF THE KIDNEYS. 



677 



Daring the attacks the symptoms resemble the acute form of 
nephritis, with acute uraemia, the occurrence of dyspnoea and of loss of 
appetite, nausea and vomiting. The high tension of the arteries is 
worse at the time of the attacks. The urine contains albumin, and is 
of low specific gravity during the time of the attack ; during the inter- 
val the albumin is found at irregular times. 

Spasmodic dyspnoea is the first, and sometimes the only symptom for 
a long period of time. After a time the renal symptoms become pro- 
nounced, pointing to the true nature of the disease. The renal disease 
is often not suspected until after the patient has had an attack of 
apoplexy. The course of this form of nephritis is varied very much 
by the occurrence of complications, notably emphysema, endocarditis, or 
cirrhosis of the liver. 

Suppurative Nephritis (Abscess of Kidney). Infectious matter 
is conveyed to the kidney either through the blood, as in pyaemia and 
ulcerative endocarditis (rarely dysentery and actinomycosis), or by the 
ureters, as when it follows pyelitis or cystitis. A wound may infect the 
kidney directly. 

Symptoms. The symptoms are those of the primary disease, and the 
affection is usually only recognized post-mortem. Or the symptoms are 
merely those of suppuration. Pus is seen in the urine only on rupture 
of the abscess into the pelvis of the kidney. 

Tubercular Nephritis. Fever, emaciation, anaemia, and prostra- 
tion characterize the course of the disease. Tuberculosis is usually 
found elsewhere. There may be no other symptoms. Sometimes 
hydronephrosis is present. A tumor is often present. It may be in 
the loins, or may be in front, above, and a few inches to the right or 
left of the umbilicus. The urine is normal or contains pus and 
detritus or even tubercle bacilli. The testicles and bladder should be 
carefully examined. 

The Degenerations. 

Degeneration may be either acute or chronic. The process is always 
secondary, due to the action of inorganic poisons, as arsenic or phos- 
phorus, or the poison of infectious disease, or is produced as the effect of 
chronic disease of the organs, or by disturbance of the circulation. 

In acute degeneration of the kidneys the urine is unchanged, or its 
quantity is diminished. It contains a little albumin, or the albumin is 
present in large amounts with casts and blood corpuscles. 

There may be no symptoms except changes in the urine, or symptoms 
of uraemia may develop at once. Dropsy and hypertrophy of the heart 
do not occur. 

Chronic degenerations in the kidneys follow chronic congestion, or are 
produced by alcoholism or syphilis. They occur in the course of pul- 
monary phthisis, of chronic suppuration, and syphilis ; they may develop 
in the course of gout or malarial cachexia. Symptoms : In the simpler 
forms there may be no clinical symptoms whatsoever. In others there 
is loss of flesh aud strength, the development of anaemia, and in rare 
instances the development of the typhoid state. 

The changes in the urine vary. It may be abundant, scanty, or sup- 



678 



SPECIAL DIAGNOSIS. 



pressed. The specific gravity is not changed, but albumin and casts 
are found. 

Amyloid degeneration of the kidney is associated with similar degenera- 
tion in other organs. It occurs in the course of phthisis, of chronic 
suppurations, of syphilis, of chronic dysentery, and is thought to occur 
in the malarial cachexia or with gout. Symptoms: The degenera- 
tion may be present without clinical symptoms. If symptoms arise 
they are due to the anaemia and cachexia that attend the primary disease, 
and to the involvement of the other organs in the same process, as the 
liver, spleen, and intestines. (Edema may be present, although it is 
more frequently absent. Uraemia is of rare occurrence. In the un- 
complicated degenerations there is no hypertrophy of the left ventricle, 
and albuminuric retinitis is a rare occurrence. 

The Urine. It may be diminished, normal, or increased ; it varies 
from time to time in the same case. It is usually very pale in color. 
The specific gravity is not constantly at one figure. Albumin is con- 
stant, aud usually is in considerable amount. Hyaline casts and white 
blood-cells are always found. When other casts are present nephritis 
probably complicates the condition. 

The diagnosis of amyloid disease is based upon the presence of the 
cause; changes in the urine; and signs of similar disease in the other 
organs. 

Sarcoma and Carcinoma of the Kidney. 

Either disease may be primary or secondary. Sarcoma may be con- 
genital. The tumor may occur at any age, but is relatively common in 
young children. In older persons it is often preceded by calculus. 
Symptoms : In some instances there are no symptoms during life. In 
others the disease may advance considerably before it presents any signs. 
If symptoms are complained of they are usually limited to pain, the 
occurrence of haematuria, or the development of a tumor. The pain is 
dull and seated in the lumbar regiou. It may be neuralgic in character, 
and, indeed, there may be a true sciatica with paresis of the leg from 
pressure of the tumor. The tumor is firm ; its surface smooth or 
nodulated. It may be felt in the loins, and in front, above the umbilicus, 
a few inches to the right or left of the median line. The descending 
colon lies in front of the tumor. The hcematuria may be constant or 
intermittent. The clots of blood may cause renal colic. 

The general symptoms are those of carcinoma. A marked rapidity 
of the pulse has been noted in several cases. In girls a premature de- 
velopment of hair on the pubes and in the axillae, and pigmentation of 
the skin have been observed. 

The tumor must be distinguished from tumors of the lymphatic 
glands, of the liver, of the spleen, and of the ovary. It must not be 
confounded with psoas abscesses and perinepliritic abscesses, which cause 
a tumor behind. 

Cystic Kidneys. 

1. Congenital. The kidney consists of a mass of small cysts filled 
with clear fluid. It may interfere with the birth of the child on account 
of its large size. 



DISEASES OF THE KIDNEYS. 



679 



2. Acquired. The cause is trauma and obstruction of the ureter. The 
symptoms are those of a renal tumor which fluctuates. The urine may 
be normal or hematuria may be present. 

Horseshoe Kidney. There are usually no symptoms. The kidney 
can usually be felt through the abdomen if its walls are relaxed, or by 
bimanual examination. 

Hydronephrosis. 

Causes. It may be congenital. Obstruction of ureter by stone ; 
pressure of tumor; twist, as in floating kidney; exudates. 

Symptoms. In addition to the symptoms of the causal condition we 
have upon the development of hydronephrosis the presence of a tumor, 
arising in the region of the kidney and extending toward the middle 
line. Sometimes fluctuation can be detected ; often not. Variations in 
size of the tumor may occur with changes in amouut of urine passed. 
Puncture and the finding of a fluid with elements of urine in it are 
valuable means of diagnosis ; but if the hydronephrosis is old this fails, 
as the fluid loses its urinary character and cannot be distinguished from 
that of an ovarian cyst. When on one side, the urine may be normal ; 
when on both sides, it is diminished ; anuria and uraemia may occur. 
If pyelitis is present the urine takes character from that. 

Pain may or may not be present. Gastric symptoms are very 
common. Constipation or diarrhoea is seen. Hypertrophy of the left 
ventricle may occur, as in chronic nephritis. 

Nephrolithiasis (Renal Calculus). 

Penal calculi vary in size from "sand," through u gravel/' to u stones." 
The latter may be from the size of a cherry to one large enough to fill 
the pelvis of the kidney. They consist usually of uric acid, and are 
hard, brownish-red or blackish, crystalline, and the larger ones in dis- 
tinct layers. More rare are calculi of calcium oxalate, extremely hard 
and nodular. Some stones have alternate layers of the two salts ; 
others are of phosphates, but usually the inside is of uric acid or cal- 
cium oxide, the phosphates having been deposited after the urine 
became alkaline. Very rare forms are of cystin, xanthin, indigo, etc. 

Symptoms. When stones are very small (sand) there are no symp- 
toms except, perhaps, occasional pain in the lumbar region. When 
larger they attempt to pass the ureter or irritate the pelvis and cause 
renal colic. The latter comes on suddenly, is very intense, radiates 
from the loin and right or left center of the abdomen down to the 
bladder, testicle, and thigh. Collapse occurs in severe cases. The urine 
may be lessened in amount, or suppressed if both sides are obstructed. 
It may contain blood and pus. The attack lasts from a few hours 
to several days. Between paroxysms there may be constant pain, and 
the urine contains pus, pelvic epithelium, often blood ; at other times 
the urine is clear and normal. Pyelitis, pyelonephritis, and hydro- 
nephrosis may develop. 

The stone usually develops in the pelvis of the kidney — not in the 
kidney itself. A stone may remain fixed in the pelvis and produce no 



680 



SPECIAL DIAGNOSIS. 



symptoms, or those of gastric disturbances, catarrh of the bladder, and 
pyelitis. 

Diagnosis. It must be distinguished from lumbago, perinephritic 
abscess, hepatic colic, aud gastralgia. 

Pyelitis. Pyonephrosis. 

Causes. Rarely primary ; usually secoudary. Severe infectious 
diseases (typhus, variola, diphtheria, pyaemia) ; toxic substances ingested 
(cantharides, etc.) ; chronic nephritis ; inflammation of the bladder or 
ureter ; strictures of the ureter or urethra ; hypertrophy of the prostate ; 
spiual palsies of the bladder ; calculus ; parasites ; blood-clots. 

Symptoms. The Urine. Pus in the urine with pelvic epithelium — 
although it is not safe to base a diagnosis on the presence of the latter ; 
casts of the cauals opening iuto the pelvis are more characteristic ; epithe- 
lial casts, aud casts containing micro-organisms. The urine is often 
increased, acid, and contains pus and albumin, rarely blood. Pain in 
the region of the kidney, often severe, is complained of, although it 
may be absent. When present, it is often of a tearing character. 
Tumor. A tumor is often present. It is most prominent in the loin or 
in the abdomen. In the latter the mass can be felt two inches to either 
side of the umbilicus, usually above the tranverse line. 

Fever is irregular, remitting, or septic. If the bladder is healthy its 
symptoms fail to aid in diaguosis. 

Perinephritic Abscess. 

Causes. Trauma ; abscess in the kidney ; pyelitis (either simple, 
calculous, tubercular, cancerous, echinococcal) ; abscess in neighboring 
organs, as the liver or lungs ; Pott's disease ; actinomycosis ; pelvic cellu- 
litis ; appendicitis. It also occurs as a primary disease in apparently 
healthy individuals or after infectious diseases. 

Symptoms. The secondary forms have symptoms of the primary 
disease, and later swelling and pain in the renal region. 

Primary form. Chills and fever, pain, difficulty in defalcation. The 
general condition suffers. Finally, in all cases there is the formation of 
a swelling in the lumbar region, at first hard ; then oedema of the skin is 
found and fluctuation detected. The abscess may descend and point 
above Poupart's ligament. It may press upward and cause dyspnoea. 
Great tenderness and pain in the region of swelling may arise and the 
pain radiate to the leg. Irregular septic fever and chills appear. Urine 
is not generally changed unless some communication with the pelvis or 
ureter has formed. The patient lies on his back, turned toward the 
affected side. The knee and hip of this side are flexed and the thigh 
rotated outward. The affection may simulate coxitis and appendicitis. 

Parasites. 

1. Eehinococcus. Comparatively rare. Usually there are no symp- 
toms until a tumor is felt. Then pain gradually develops. The cyst 



DISEASES OF THE KIDNEYS. 



681 



may open into the pelvis of the kidney, and cysts or scolices be dis- 
charged, with colic. 

Pyelitis and cystitis may also develop. 

Echinococcus cyst may inflame and lead to general pyaemia. Punc- 
ture of the discovered tumor is otherwise the only means of diagnosis. 

Hydronephrosis and ovarian tumors must be distinguished. Punc- 
ture is necessary. 

2. Distoma Hcematobium. Common in Egypt and Abyssinia. Eggs 
collect in great masses in the urinary passages, and lead to inflammation, 
ulcers, stenosis, etc. Eggs found in the urine alone make the diagnosis 
possible. 

3. Strongylus Gigas. Very rare. Symptoms of pyelitis. (The para- 
site is of the size of a ground-worm.) 

4. Filaria Sanguinis Hominis. Causes chyluria. Embryos may be 
found in the urine. 

Floating' Kidney. 

Floating kidney is usually seen in women after the age of forty, who 
have had considerable hard work and borne many children. Its occur- 
rence is frequently preceded by a history of unusual lifting or strain, 
followed by tearing or dragging sensations in the abdomen. Pain may 
continue for several weeks after the injury, and then subside and the 
occurrence be forgotten, or subjective sensations may continue. 

The symptoms that arise are due to the local dragging or pulling of 
the kidney on its mesonephron, or to reflex symptoms, or to pressure 
upon adjacent organs. 

The pain that attends floating kidney is usually referred to the right 
or left of the median line; sometimes to the hypogastrium. It may 
be constant, dull, and aching in character. Paroxysms may arise in the 
course of the constant pain, or a paroxysm alone take place. The par- 
oxysms continue for three or four days, during which time other subjec- 
tive symptoms are more pronounced. Nausea may occur with the 
paroxysms, or be more or less constant. Sometimes vomiting takes 
place. In addition to pain a dragging sensation is experienced, and the 
patient may appreciate the presence of a tumor or lump in the abdomen, 
as well as its movability when she moves about. The reflex symptoms 
are chiefly referable to the nervous system. Emotional disturbance is 
observed when the organ is out of its capsule. Hysteria may be present. 
There is often great depression of spirits, and often hypochondriasis. 
From pressure jaundice may occur, and the intestine may be occluded. 

The urinary symptoms are of interest. When the local pain and 
other symptoms are more pronounced the urine may be scanty. In one 
case it was reduced to sixteen ounces in twenty-four hours. At the same 
time that the urine is scanty, hydronephrosis will develop. It will be 
referred to again. As the kidney slips back into its bed the twisting 
of the ureter is relieved, and discharges of large amount of urine take 
place. Palpitation of the heart is a common reflex symptom. 

Objective Symptoms. The abdominal walls are usually relaxed, and 
may or may not contain a large amount of fat. On palpation a tumor 
can be found to the right or left of the median line, freely movable and 



682 



SPECIAL DIAGNOSIS. 



alternating its position with change in position of the patient. If the 
tumor is situated on the right side, it may be in close proximity to the 
liver, or be felt opposite the umbilicus, or often in the iliac region. When 
near the liver, by careful palpation the fingers can be introduced be- 
tween the border of the liver and the mass. Usually it does not move 
with respiration, but sometimes it is found to do so. On the left side it 
may be as high up as the margin of the ribs. It generally is felt in the 
mid-clavicular line a little above the level of the umbilicus. It is like- 
wise movable. On palpation the tumor is found to be of the shape of the 
kidney, firm in character, and at times quite painful. The hilus of the 
kidney and the vessels going to it, can at times be felt. Palpation fre- 
quently causes nausea, and may excite an attack of palpitation of the 
heart, or pronounced nervous symptoms. 

In a case recently under the writer's care, about once a month the 
woman, aged fifty-five, would experience pain in the abdomen, to the 
right and above the umbilicus. At times nausea and vomiting accom- 
panied the attacks. At other times marked depression or hysteria. 
Anuria always occurred and continued for a variable time, not longer 
than five days. With one of the paroxysms the tumor was found in 
the region of the gall-bladder, movable with respiration, but distinctly 
defined from the liver by placing the fingers between the lobe and kidney. 
It moved with each change of position of the patient, and at first the 
hilus could be distinctly felt. As the pain continued the anuria per- 
sisted, and a marked change in the tumor was observable. It grad- 
ually increased in size, and a portion of it fluctuated ; it was round 
and partook of the character of a cyst. The fluctuation was detected 
by placing the hand on the tumor in front and pressing firmly toward 
the other hand placed in the loin above the pelvis. When the anuria 
disappeared, a copious discharge of urine took place and the swelling 
subsided. 

Floating kidney may be confounded with tumor of the gall-bladder, 
tumor of the pylorus, and with tumors in the pelvis. It is not likely 
to be confounded with an omental tumor, carcinoma, or tuberculosis, be- 
cause the phenomena of these processes are not present and ascites does 
not occur, nor is there rise of temperature, as in many cases of tuber- 
culosis. Tumor of the gall-bladder is distinguished by the absence of 
previous history or of symptoms or signs indicating disease of the gall- 
ducts. If jaundice is present, it is not so intense as in tumors of the 
gall-bladder. While the gall-bladder is movable, it is not so distinctly 
so as floating kidney. Anuria does not occur. 

In cancer of the pylorus the emaciation and anaemia are more pro- 
nounced than in floating kidney. The vomiting, usually characteristic 
in that affection, and the physical signs of dilated stomach, can be made 
out. Tumors of the pelvic organs are determined by examination 
according to the usual methods. 



CHAPTER VIII. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

Inspection of the Blood. 

The blood consists of corpuscles and serum. The corpuscles are four : 

(1) red blood-cells ; (2) nucleated red blood-cells ; (3) blood-plaques ; 
(4) leucocytes. 

The ordinary red blood-cells measure -g-^Vo ^ ncn > the leucocytes, 
Yeus inch. There are from 8000 to 15,000 leucocytes iu a cubic milli- 
metre of blood, or 1 to 350-700 red blood-cells. 

Inspection of the blood may be (1) with the eye alone, or (2) with 
special instruments. 

1. Inspection with the Unaided Eye. This gives but little 
information. It serves to distinguish bright-red arterial blood from 
darker venous blood, and also indicates when arterial blood has become 
deficient in oxygen from any of the causes of venous engorgement and 
cyanosis. Iu chlorosis and hydremias the blood is pale, as though 
mixed with water, while in severe leukgernias it has a slight milky 
tinge. On the other hand, in carbonic oxide poisoning the blood be- 
comes of a brighter red, while iu poisoning with chlorate of potash and 
anilin, and in grave cases of poisoning with nitrobenzol and hydro- 
cyanic acid, it is brownish-red or chocolate-colored. 

2. Inspection with Special Instruments. These are the micro- 
scope, the hsemoglobinometer, the hsemocytometer. 

The Microscope. Inspection with the microscope reveals red and 
white blood-cells and blood-plaques. In an adult man the red cells 
number from 5,000,000 to 5,500,000 to the cubic millimetre ; in an 
adult woman the number is usually less, being from 4,500,000 to 
5,000,000. The proportion of white to red cells is about 1 to 500. 
There is a normal increase of white cells during digestion. 

The microscope is, of course, essential to blood-counting, to the 
study of cover-glass preparations according to Ehrlich's methods, and 
to examinations for parasites. 

Hcemoglobinometers. Gowers' hsemoglobinometer (Fig. 123) consists 
of (1) a closed tube, d, containing coloring matter representing the 
color human blood should have normally if diluted one hundred times ; 

(2) a corresponding empty tube, c, graduated in an ascending scale 
from 10 to 120 per cent. ; (3) a capillary glass tube, B, marked at 
20 cubic millimetres ; a small guarded lancet, F, and a small bottle 
with pipette-stopper, a, for distilled water. A few drops of distilled 
water are first placed in the empty tube, c, to prevent the coagulation 
of the blood, which would occur if the blood were first put in the tube. 
The finger or lobe of the ear, previously cleansed with water and 



684 



SPECIAL DIAGNOSIS. 



ether, is then deeply stabbed with the lancet, so that the blood will flow 
freely, care being taken to avoid squeezing the punctured part ; 20 cubic 
millimetres of blood are then quickly drawn up in the capillary tube 
and at once blown into the graduated tube, which is shaken to allow 
the blood to become diffused in the water. The tubes containing the 
standard coloring matter and the diluted blood are now held up, side by 
side, against a sheet of paper, and more distilled water added, drop by 



Fig. 123. 




Gowers' heernoglobinometer. 



drop, with repeated shakings, until the colors in the two tubes match- 
The height to which the column of diluted blood and water has risen 
in the graduated tube represents the percentage of haemoglobin con- 
tained in the blood tested. 

Fleischl's haBmometer consists of a small metal table with an aperture 
in the middle, and under this a reflector made of plaster- of-Paris. The 
opening is occupied by a small well having a glass bottom and divided 
into two equal compartments. The standard color of the blood at 
different dilutions is represented by a wedge of glass colored with Cas- 
sius purple, which is of course pale in color at the extreme edge and 
deepens in intensity with its thickness. This wedge of glass is moved 
under the table by a rack and pinion, and is accompanied by a graduated 
scale. One -half of the well receives simply the white light from the 
plaster-of-Paris reflector, while the other rests upon the ruby glass and 
obtains light through it. A small pipette and several capillary tubes 
about f inch in length and mounted on slender metal handles are em- 
ployed to obtain the necessary amount of blood ; each one of them will 
hold enough normal blood when properly diluted to produce a color 
corresponding to that of the ruby glass at the 100 mark. For use, 
one end of a capillary tube is carefully lowered upon a drop of blood 
which immediately fills it; the tube is then at once washed in one of 
the compartments of the well, which contains some water. The com- 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 685 



partments are now equally filled with water and the well so placed that 
the side containing blood receives white light while the other receives 
light through the wedge of glass. The glass is now moved by the rack 
and pinion until the intensity of the color in the two compartments is 
the same, and the percentage is then read off through the small opening 
behind the well. 

These instruments are about equally accurate, and both are gradu- 
ated for a higher percentage of haemoglobin than is the average with 
Americans. 

Hcemocytometers. The hsemocytometers, or blood-counters, most 
frequently used in this country are those ot Gowers and Thoma-Zeiss. 

Gowers' instrument consists (1) of a small pipette, A, which, when 
filled, holds exactly 995 cubic millimetres. It is for measuring the 
diluting fluid ; (2) a capillary tube, B, graduated for 5 cubic millimetres ; 
(3) a small glass jar, d, in which the dilution is made ; (4) a small glass 



Fig. 124. 




Hsemocytometer oi Gowers. 



stirrer, e, for mixing the blood and diluting fluid in the jar ; (5) a small 
lancet, f; (6) a brass stage-plate, o, carrying a glass slip on which is a 
cell one-fifth of a millimetre deep. The bottom of the cell is divided into 
one-tenth millimetre squares. On the top of the cell rests the cover- 
glass, which is kept in place by the pressure of two springs proceeding 
from the ends of the stage-plate ; 995 cubic millimetres of the diluting 
fluid are measured and blown into the mixing jar ; then 5 cubic milli- 
metres of blood are added and the two thoroughly mixed. A small drop 
of the mixture is then placed upon the cell, the cover-glass gently 
adjusted and held in place by the two springs. From five to ten min- 
utes should be allowed to elapse, so that the corpuscles will have time 



686 



SPECIAL DIAGNOSIS. 



to settle to the bottom of the cell. The stage-plate is then placed under 
a microscope, and the number of red blood-cells in ten squares counted. 
This number, multiplied by 10,000, gives the number in a cubic milli- 
metre of pure blood. It is better to count a large number of squares, take 
the average, and multiply by 100,000. This number is the product 
of the dilution (200) by the square surface of the cells, 100 (10 X 10), 
and again by 5, the depth of the cell : 200 X 100 X 5 = 100,000. To 
facilitate seeiug the fine lines marking the squares, a soft black lead-pencil 
should be gently rubbed over them before the drop of diluted blood is 
placed on the cell. Counting of the white cells is made much easier if 
the diluting fluid is colored a pale violet with a very small quantity of 
gentian-violet. The white cells then appear a distinct blue, while the 
red cells are unaltered. As diluting fluids, a 1 per cent, solution of 
common salt, or a 2J per cent, solution of bichromate of potash, as 
recommended by Daland, may be used. 

Another hsemocytometer is the Thoma-Zeiss. It is preferred by 
most clinicians. It consists of a heavy glass slip (a) in the middle of 
which is a cell (B) exactly millimetre in depth. The cell is 
limited at the periphery by a circular gutter to prevent fluid placed 
upon the cell from flowing beyond it between the slip and cover-glass. 
The floor of the cell is ruled into squares whose sides are mm « 



Fig. 125. 





0.100mm. 

400 S^Itt. 




Thoma-Zeiss blood-counting apparatus. 



Double lines mark out large squares containing twenty-five small 
squares. Thick, carefully ground cover-glasses (D) are provided in the 
case. The ordinary Potain melangeur (8) is used to measure and mix 
the blood. It consists of a capillary tube the upper portion of which 
is blown into a chamber (E) holding 100 c.mm. The stem of the tube 
is graduated at 0.5 and at 1 c.mm. 

To use the instrument a drop of blood is obtained from the finger 
or lobe of the ear, and 0.5 or 1 c.mm. measured. The point of the 
tube is wiped quickly free from excess of blood, and inserted into the 
diluting fluid, which is drawn up to the level of the mark 101. 
The proportion of blood and diluting fluid is then J or 1 to 100 c.mm. ; 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 687 



they are thoroughly mixed by shaking with the aid of a small glass 
ball contained in the chamber. The diluting fluid in the stem of the 
melangeur is now blown out, and a drop of the blood mixture placed on 
the cell. The cover-glass is now adjusted carefully to avoid bubbles, 
and to prevent the escape of the fluid between it and the slip. The 
cover-glass should now be pressed firmly down until Newton's color 
rings appear, and then the slip allowed to stand for five or ten minutes 
until the corpuscles have settled to the bottom of the cell. The number 
of corpuscles in twenty-five squares is now counted, and from this the 
number in a cubic millimetre of pure blood obtained by multiplying the 



Fig. 126. 





























































































J 0 


































0 0 
























































it 













Appearance of blood in the Thoma-Zeiss cell. 

average number in one small square by 400,000. This number is the 
product of 100 for the dilution, 400 (20 X 20) for the square surface of 
the cells, and 10 for the depth of the cells. The results are accurate in 
proportion to the number of cells counted. 

The Hcematokrit. The hsematokrit is an instrument devised for the 
estimation of the number of red corpuscles by means of centrifugal 
force. In Daland's article 1 will be found a full description of the 
instrument, and from the same article the following method of using it 
is abstracted. The finger or ear and apparatus are prepared as above. 
An incision is made deep enough to produce a good-sized drop of blood. 
This is drawn up into a capillary pipette by means of suction through 
an attached rubber tube, and an equal amount of the diluting solution 
(2.5 per cent, solution of potassium bichromate) added and thoroughly 
mixed in a watch-glass. The hsematokrit tube is then immediately 
filled by suction, one finger being placed over the free end when the 
rubber tube is removed, to prevent the loss of fluid. The filled tube is 
then placed in the frame of the hsematokrit, and also a second prepared 
exactly as the first. The larger wheel is then rapidly rotated one 
hundred times, and the result read from the scale multiplied by 4 2 
gives the percentage volume. (It was found by experimenting that 
each percentage volume represents about 100,000 corpuscles. We 
therefore add five ciphers to the percentage volume obtained, and the 

1 University Medical Magazine for November, 1891. 

2 2 for the dilution and 2 to make it a percentage, as there are only 50 divisions on the scale. 



688 



SPECIAL DIAGNOSIS. 



number of red corpuscles per c.mm. is indicated. 1 ) The whole pro- 
cedure should be done as quickly as possible. Daland found the pipette 
made by Zeiss for measuring and diluting the blood in the estimation 
of white corpuscles to be particularly serviceable in diluting the blood 
for the haematokrit. The blood is drawn up to the 1 mark, a bubble of 
air is then admitted and the solution drawn up to the same mark, the 
blood ascending further into the pipette. They are then blown into a 
watch-glass and are so mixed ready for the haematokrit tubes. 

Oligocythcemia. Oligocythaemia is the name applied to a diminution 
in the number of red blood-cells, from whatever cause. It is usually 
associated with oligochromcemia (deficiency of haemoglobin), which, how- 
ever, in idiopathic anaemia is absolute, not relative. Oligocythemia, 
when marked, can be detected with the microscope alone, and can be 
estimated accurately with the haemocytometer or haeinatokrit (see Fig. 
127). 

Leucocytosis. Leucocytosis is a temporary increase in the number of 
white blood-cells. It occurs normally after digestion and in newborn 
children. Pathologically, it occurs in pneumonia, in glandular swell- 
ings, sarcoma, osteomyelitis, pernicious anaemia, and chlorosis. It is 
best determined by the use of a haemocytometer. Dry preparations 
according to Ehrlichias method are necessary for a study of the various 
forms of leucocytes (see under Leucocythaemia, page 693, and Figs. 
128 and 129). 

Poikilocytosis. This is a condition in which the red blood-cells are 
very irregular in shape — oval, pointed, angular, or reniform (see Fig. 
127). It is a common accompaniment of severe anaemia, particularly 
leucocythaenia and idiopathic anaemia. 

Microcythcemia. This is a condition of the blood characterized by 
the presence of cells containing haemoglobin, but much smaller than an 
ordinary red corpuscle. They are found in anaemias and toxaemias. 

Melancemia. Melanaemia is a rare condition in which black, brown, 
or yellow granules are seen floating, either free among the blood-cells, 
or, more commonly, enclosed in cells resembling leucocytes. They are 
present in malarial fevers, particularly the chronic forms, and in 
relapsing fever. 

Anaemia. 

Anaemia is a condition characterized by a reduction in the number of 
red blood-cells, or of their contained haemoglobin, or of the albumin, or 
of all combined. 

For clinical purposes it is convenient to make a number of divisions 
of anaemia, though on aetiological and pathological grounds a number of 
them will no doubt soon be grouped together. 

The following classification of anaemias, modified from Griffith, 2 is 
helpful in the study of anaemia. In it both pernicious anaemia and 
chlorosis are regarded as haemolytic in origin, the destructive agent 
probably being absorbed from the intestine. 

1 Thus if the scale shows 12, we multiply by 4 to get the percentage volume, and add five ciphers, 
4 X 12 = 48, = 4.800,000. 

2 " Diseases of the Blood," Keating's Cyclopaedia of the Diseases of Children, 1890, hi. 770. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 689 



Non-cytogenic, 



Anemia, •{ 



Cytogenic, 



f Haemolytic, 
Oligocythaemic, 

Leucocytic, 
Non-leucocytic, 



Pernicious anaeniia. 
Other toxic anaemias. 
Chlorosis. 

Parasitic anaemia (some forms). 

Parasitic anaemia (some forms) . 
Post- hemorrhagic anaemia. 
Anaemia from loss of albumin. 
Anaemia of malnutrition. 

/-Splenic. 
Leucocythaemia, < Lymphatic. 

t Medullary. 

Splenic anaemia. 
Lymphatic anaemia. 
Hodgkin's disease. 



I. Toxic Anjemias. Anaemia may be toxic in origin, the poison 
being developed either in the body or introduced from without. Tox- 
aemia is at least sometimes a factor in the anaemias which develop in the 
course of acute infectious diseases or during convalescence from them ; 
according to Hunter, pernicious anaemia would be classed under this 
head. The metallic poisons, particularly lead, mercury, arsenic, phos- 
phorus, the potassium salts, especially the chlorate ; certain of the auti- 
pyretics, notably pyrodin, and the aniline preparations are capable of 
producing anaemia. 

' Fig. 127. 




Severe anaemia. (Reproduced from colored plate.) Dry preparation. Stained with eosin- 
methyl-blue. X 300. Great poikilocytosis of red cells. Many macrocytes and microcytes. To the 
left above, a mononuclear leucocyte with bluish nucleus and nearly unstained cell-body. 



II. Parasitic Anemias. Anaemia may be parasitic. 1. To this 
class belongs the anaemia of malaria, which is believed to be due to the 
Plasmodium malarioe, described by Laveran. 

2. Certain intestinal worms are found associated with marked anae- 
mias, (a.) The bothriocephalus latus sometimes produces a disease closely 
resembling pernicious anaemia, but whether by direct destruction of the 

44 



690 SPECIAL DIAGNOSIS. 

blood or by the development of toxic products themselves destructive, 
is uncertain ; it may be present in large numbers without giving rise to 
anaemia. 

(6) The ankylostomum duodenale is believed to be the cause of the 
anaemia known variously as Egyptian or African chlorosis, tropical 
anaemia, brick-burner's anaemia, etc. 

(c) The anguillula intestinalis is the cause of " Cochin- Chi u a diar- 
rhoea" and its associated anaemia. 

3. The filaria sanguinis hominis may produce anaemia by blocking 
up the lymph channels. 

4. The Bilharzia hcematobia may produce anaemia by inducing 
haematuria. 

Fig. 128. 




Grave anaemia with leucocytosis. (Reproduced from colored plate.) Dry preparation. Stained 
with eosin-methyl-blue. X 300. The red blood-cells are scanty, pale, and show poikilocytosis ; 
the white cells, with the exception of one cell (to the left, below) are polynuclear, with dark-blue 
nucleus and faintly stained violet cell-body. To the right, above, is a nucleated red blood-cell 
(microblast) with dark-blue nucleus and faintly stained red cell-body. (H. Rieder.) 

III. Anemia from Hemorrhage. Anaemia may be due to 
hemorrhage. In addition to accidental and post-partum causes, purpura, 
haemophilia, menorrhagia, and metrorrhagia are frequent causes. 

IY. Anaemia from Constitutional and Local Diseases. 
Anaemia is often a marked symptom of constitutional and local diseases, 
such as tuberculosis, syphilis, cancer, rheumatism, scrofula, scurvy, 
rickets, Bright's disease, chronic catarrhal gastritis, and others. The 
anaemia here may be due to the malnutrition and interference with 
digestion brought about by the disease, or, as in the case of Bright's 
disease, in part to the direct loss of albumin, and in dyspeptic condi- 
tions to inability to take and assimilate food. 

V. Anaemia of Malnutrition. Anaemia may also be the result 
of malnutrition from deficient or improper food, or from the poisonous 
influences of unsanitary surroundings. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 691 



Chlorosis. Chlorosis is a form of anaemia occurring especially in 
young girls about the period of puberty, and characterized by great 
pallor of the skin aud mucous membranes, with a greenish tint of the 
skin, a pearly eye, languor, weariness, suppression or irregularity of 
menstruation, venous hum in the vessels, dyspnoea, palpitation, dizzi- 
ness, neuralgias, and an unstable condition of the nervous system. In 
spite of the extreme pallor there is usually but little loss of flesh. The 
bowels are usually constipated, the urine abundant, pale, and of low 
specific gravity. The digestion is disturbed, the appetite capricious, aud 
the patients sometimes crave unwholesome things, such as earth, slate- 
pencils, vinegar, and the like. A systolic murmur over the base of the 
heart is common. Gastralgia is more common than in other forms of 
anaemia. 

The changes in the blood are very important. There is always a 
marked reduction in the haemoglobin, the percentage falling sometimes 
to 30 or 25 per cent, of the normal. The red blood-cells are usually 
also reduced, but not in the same proportion as the haemoglobin. For 
example, there may be 4,000,000 red cells, but only 30 per cent, of 
haemoglobin. Sometimes there is no diminution in the number of red 
cells ; the latter, however, appear pale, vary considerably in size, micro- 
cytes and macrocytes and occasionally poikilocytes are present, and in 
severe cases nucleated red corpuscles are found. The number of leuco- 
cytes varies but little from the normal, but there may be a slight increase. 
Occasionally there is a rise of temperature, but it is probably due to 
some complication. 

The cause of chlorosis has not been determined satisfactorily. Vir- 
chow has established the existence of congenital narrowing of the blood- 
vessels. Sir Andrew Clark thinks it is due to the absorption of poisonous 
matter from the intestine ; the great benefit that follows saline purga- 
tives in many cases indicates that faecal toxaemia is a factor in these 
cases. Forchheimer 1 also looks upon it as intestinal in origin. 

Sex and puberty are predisposing causes ; but chlorosis may occur 
in boys, and appear in girls before puberty, and in young women con- 
siderably after that period. The prognosis is favorable ; it may, 
however, be complicated with gastric ulcer, chorea, tuberculosis, and 
endocarditis. Recovery is often slow and interrupted by relapses. 

Idiopathic Aneemia. Idiopathic, or- pernicious, anaemia is a form 
in which the diminution of red blood -cells reaches an extreme degree. 
It occurs without adequate known cause, and runs, with remissions, a 
progressive course, and usually terminates in death. 

The disease usually develops slowly and insidiously, the patient 
presenting the ordinary symptoms of anaemia — pallor, weakness, 
shortness of breath, palpitation, venous murmurs, loss of appetite, and 
impaired digestion. As the disease progresses the skin becomes of a 
pale lemon hue, weakness and dyspnoea increase, the patient has attacks 
of dizziness, faintness, and ringing in the ears ; there may be slight 
oedema, and hemorrhages from the nose, the bowels, and into the retina, 



1 Trans. Assoc. Amer. Phys., 1893. 



692 



SPECIAL DIAGNOSIS. 



occur. The hemorrhages are small and distinct in the skin and mucous 
membranes. The urine is of low specific gravity and usually contains 
an increased amount of uric acid. According to Hunter, the urine 
should be dark and contain a large amount of pathological urobilin, 
some renal epithelium, a few casts containing blood pigment, and an 
increased amount of iron. The bowels may be disturbed by diarrhoea. 

A peculiarity of the disease is the occurrence of fever of an irregular 
type. The temperature rarely rises higher than 102° or 103° in the 
eveniugs and is followed by a morning remission. It is not usually 
present in the early stages of disease, may be absent for weeks at a 
time when the disease is fully developed, and may cease entirely in the 
later stages. 

In spite of the extreme exhaustion, anaemia, and widespread func- 
tional disturbance, there is no emaciation ; the patient appears well 
nourished. 

The blood appears pale and watery to the naked eye ; there is diffi- 
culty in obtaining by puncture a sufficiently large drop for examina- 
tion. The specific gravity is lowered, being 1028 instead of 1055. It 
has been found deficient in fibrin, iron, and nitrogen. 

The blood changes in idiopathic anaemia are characteristic, and are 
essential to the diagnosis of the disease. In brief, they are : (1) very 
great reduction in the number of red blood-cells ; (2) an absolute 
diminution in the amount of haemoglobin, but, as compared with the 
number of red cells, a proportionate increase ; (3) considerable variation 
in the size of the cells, the average size of the cells probably being larger; 
(4) poikilocytosis ; (5) nucleated red blood-cells ; (6) degenerative 
cells. 

Reduction in the number of red blood-cells (oligocythemia) reaches a 
more extreme degree in pernicious anaemia than in any other disease ; 
the number often falls below 1,000,000, and in one case reported by 
Quincke 3 the number was only 143,000 per cubic millimetre. The 
shape of many of the cells is altered ; they are oval, elongated, bent, or 
have projections of their substance (poikilocytosis). The size of the cells 
varies ; there are microcytes and megaloblasts ; but the occurrence of a 
distinct proportion of large nucleated red blood-cells (megaloblasts) is 
regarded by Ehrlich as almost diagnostic. The average size of the red 
cells seems to be increased, and so is the proportiouate amount of 
haemoglobin in each cell. The latter is a very characteristic symptom 
(the only one, according to Hunter). There are also red corpuscles 
which are stained by methylene-blue ; these are regarded as degenera- 
tive by Ehrlich. The leucocytes are " usually diminished in number, 
showing; a relative increase in the small mononuclear elements 
(lymphocytes, small transpareut forms), while the multinuclear elements 
are relatively diminished, sometimes being under 50 per cent." 2 

The blood condition is not constant, but is subject to wide varia- 
tions. Von Noorden has recently found that in a very short time a 
change in the form of the blood, a " formal " crisis, may occur, of such 
a character that before a period of improvement a " formal" overflow 

1 Deut. Arch, fiir klin. Med., Bd. xx. 

2 W. S. Thayer : Boston Med. and Surg. Journal, February 16 and 23, 1893. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



693 



of the blood with polynuclear leucocytes and nucleated red blood-cells 
occurs, whereas, before a period in which the blood becomes worse, and 
before the final stage, the blood becomes poor in leucocytes and in 
nucleated red blood-cells. 1 

The aetiology of the disease has not been determined satisfactorily. 
It is more common in Germany and Switzerland than in other parts of 
Europe or America. It occurs most frequently after the twentieth 
year, and between that and the age of fifty. Excluding the influ- 
ence of pregnancy and parturition, sex makes no difference. Previous 
exhausting disease, chronic gastric and intestinal catarrh, great physical 
over-exertion, exposure, great shock or fright, precede in certain cases 
the development of the disease. 

Petrone and Halst regard the disease as infectious and its germ 
identical with that found by Frankenhauser. Von Jaksch supposes 
that it is brought about by a living contagion. Hunter traces the cause 
to a poison produced by bacteria in the gastro-intestinal canal. The 
cases of Gibson, 2 in which cure or great improvement followed the use 
of beta-naphthol, tend to support Hunter's view. 

There are no constant post-mortem lesions in pernicious anaemia, 
unless it be the deposit of iron in the peripheral zone of the liver 
cells. 3 

Diagnosis. The most important diagnostic features of the disease 
are extreme oligocythemia, relatively high percentage of haemoglobin, 
great poikilocytosis a noticeable number of large nucleated red blood- 
cells (gigantoblasts), and average iucrease in the size of the cells, and 
all this without emaciation or discoverable local disease which can bear 
a causative relation to the anaemia. In addition, retinal, subcutaneous 
and submucous hemorrhages, a urine with high specific gravity, high 
color, with urobilin in excess, alternating with urine of low specific 
gravity, in the absence of organic disease, point to idiopathic or per- 
nicious anaemia. 

Leucocytheemia. — Leucocythaemia, or leukaemia, is a chronic dis- 
ease of the blood-making organs characterized by a great and persistent 
increase in the white blood-corpuscles ; a diminished number of red 
blood-cells, which are altered in shape and size, and display nucleated 
and degenerate forms; a lessened amount of haemoglobin, and by en- 
largement of the spleen, lymphatic glands, or medulla of bone. The 
disease occurs twice as frequently in men as in women, and two-thirds 
of the cases appear between the twentieth and fiftieth years. In 
women pregnancy, parturition, and the cessation of menstruation are 
causative factors, while in both sexes depressing influences upon body 
or mind, and antecedent disease, particularly malarial fever, have a 
distinct influence. 

Gowers 4 believes that a history of intermittent fever can be traced 
in one-fourth of the 150 cases collected by him. 

The first symptom noted is generally enlargement of the abdomen; 

1 Quoted by Weiss, Diagnostiches Lexikon. 

2 Edinburgh Medical Journal, Oct. (?), 1892. 

3 Hunter : Lancet, 1888. 

4 Reynolds' System of Medicine, Philadelphia, vol. iii. 481. 



694 



SPECIAL DIAGNOSIS. 



subsequently the patient complains of pain in the splenic region, weak- 
ness, dyspnoea, hemorrhage, oedema, and digestive derangements. Occa- 
sionally profuse hemorrhage from a trifling cause, as the drawing of a 
tooth, has been the earliest symptom noted. The increase of white 
cells and diminution of red cells is progressive, and soon makes itself 
evident in the pallor of skin and mucous membranes, and in increasing 
weakness and dyspnoea. 

In the splenic form of the disease the spleen steadily enlarges, but 
may attain considerable size before the patient becomes aware of it. 
The enlargement is not usually painful, but gives rise to a feeling of 
distention, weight, and dragging. There may be tenderness on palpa- 
tion and pressure, and sometimes the patient complains of sharp stab- 
bing pains, due either to attacks of local peritonitis or to sudden 
enlargement of the spleen and consequent stretching of the capsule. 
The splenic enlargement is uniform, so that its shape and characteristic 
notch are unchanged. Moreover, the spleen remains in contact w T ith 
the abdominal walls, lying in front of the splenic flexure of the colon, 
pushing aside the descending colon and small intestines, moving with 
respiration, and presenting the usual physical signs of a solid organ. 
Not infrequently the enlargement is so great as to fill the left hypo- 
chondriac and iliac regions, and reach beyond the middle line toward 
the right groin. Sometimes a venous hum can be heard over it. 

As the result of this enlargement the diaphragm is pushed upward, 
increasing the dyspnoea already caused by anaemia, and sometimes in- 
ducing palpitation. The gastric functions are disturbed from pressure, 
vomiting, and other symptoms of dyspepsia being common. 

A rise in temperature is a very common symptom. The fever is of 
irregular type, usually with nocturnal exacerbations, the temperature 
not often rising above 102°. The febrile type may be intermittent or 
remittent, and sometimes there are periods of apyrexia. 

The pyrexia is said to be the most marked toward the close of the 
disease. Gowers states that the cases in which there is most fever are 
usually those of rapid course, considerable dropsy, and extensive hem- 
orrhage. 

As the disease progresses, weakness increases ; anaemia becomes more 
intense; dropsy of the subcutaneous tissues, peritoneum, or pleura 
occurs ; hemorrhages from the nose, gums, bowels, stomach, lungs, or 
uterus further exhaust the patient; digestion is poor, and diarrhoea is 
common. 

Headache and tinnitus are frequent symptoms, occasionally delirium 
and coma may occur, and deafness is not uncommon toward the close 
of the disease. The eyes may be the seat of leukemic retinitis. 

The liver is enlarged, often to a considerable degree, but without 
special symptoms. The same is true of the lymphatic glands and 
other adenoid tissue. The marrow of the bones becomes the seat of 
disease in some cases, but it does not usually give rise to symptoms 
during life; certain bones, however, may be tender. 

The Blood. The most characteristic and important changes from 
a diagnostic point of view occur in the blood. The blood when drawn 
from the finger is strikingly pale and whitish, an appearance supposed 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 695 

at one time by Bennett to be due to admixture of pus. It coagulates 
slowly, is of lower specific gravity than normal, and its alkalinity is 
diminished. When placed under the microscope it is at once seen that 
the number of white cells is greatly increased. If a drop of blood be 
mixed with some distilled water containing a small quantity of gentian- 
violet, the white cells are stained a decided blue and can be picked out 
with the greatest ease. Instead of there being one white cell to 300 
or 500 red, the ratio falls as low as 1:5, or 1:3, or even lower. 
Authorities differ as to the degree of increase necessary to distinguish 
leucocythsemia from leucocytosis, some including all in which the ratio 
is 1 : 50 or lower, and others excluding those in which the ratio is 
greater than 1 : 20 or 1 : 12. 

Not only are the white cells greatly increased, but they vary consid- 
erably in size and react differently to staining fluids. 

Ehrlich has described five varieties of leucocytes. The important 
points in regard to their presence are: (1) the small mononuclear 
elements are diminished; (2) the great difference in size of the multi- 
nuclear elements ; (3) the presence of myelocytes, elements in which the 
protoplasm is filled with fine neutrophilic granules; (4) the presence of 
a normal proportion of eosinophiles in so extensive an increase of leuco- 
cytes. 1 Satisfactory study of these can be obtained only by cover-glass 
preparations. The greatest care should be taken to have a perfectly 
clean, dry cover-glass, which should be handled with forceps to avoid 
moisture and soiliug. A small drop of blood is pressed between two 
cover-glasses, as in the preparation of sputum for staining. The blood 
may be then " fixed " by being heated at a high temperature for some 
time, or by immersion for half an hour in a solution of equal parts of 
absolute alcohol and ether. The prepared cover-glass should then be 
immersed for a few minutes in a solution of eosin : 

Eosin 0.5 

Alcohol (70 per cent.) 100.0 

This solution should be diluted one-half before using. The cover- 
glass should then be dried and stained for three or four minutes in a 
saturated aqueous solution of methylene-blue, also diluted one-half 
before using. The red corpuscles are .stained red, the nuclei blue, the 
eosinophile granules a brilliant red. Thayer says the following makes 
a satisfactory solution : 



Saturated aqueous solution of acid fuchsin 2 

Water 3 

Saturated aqueous solution of orange-green 6.25 

Saturated aqueous solution of methyl-green , 6 

To be added, drop by drop, while shaking the solution : 

Water . 15 

Alcohol 10 

Glycerin 5 



The specimen, fixed as before, is stained in this solution for from 
two to five minutes, washed in water, and dried in the air, or, if the 
specimen has been heated for an hour or more, between filter-paper, and 



1 W. S. Thayer : loc. cit. 



696 



SPECIAL DIAGNOSIS. 



mounted in oil or balsam. Specimens heated for one or two hours stain 
better than those which have been treated only a short time. The red 
cells appear oraDge or buff, the nuclei of the colorless corpuscles green, 
the neutrophilic granules a violet or lilac color, the eosinophilic granules 
a deep red. The nuclei of nucleated red corpuscles, when present, are 
stained an intense deep green, almost black. 1 

The essential points in the diagnosis of leucocythemia are: 1. Such 
an excess of leucocytes in the blood that the ratio of white to red falls 
below 1 : 50 or 1 : 20 ; if the ratio is higher, the white cells should 
show a progressive increase. The individual leucocytes vary in size 
and other characteristics, as already described. 2. Enlargement of the 
spleen or lymphatic glands. 3. The occurrence of hemorrhages and 



Fig. 129. 




Mixed leukaemia. (Reproduced from colored plate.) Dry preparation. Fixed with picric acid. 
Stained with hematoxylin. X 300. The red blood-cells clear bluish-gray, two of them (one to the 
right of the middle, one to the left below) nucleated, with nucleus stained a deep dark-blue, almost 
black. The white cells for the most part mononucleated ; several are polynucleated, of moderate 
size, with dark-blue nuclei. (H. Rieder.) 

dropsies unexplainable by disease of heart, kidneys, or other organs. 
4. The symptoms of anemia in a high degree, as dyspnoea. 5. Leuk- 
emic retinitis. 6. Anemic fever. 

In splenic ancemia there is present the same enlargement and the gen- 
eral symptoms, though hemorrhage is not so common. Leucocythemia 
is distinguished from it by the great excess of leucocytes and by their 
special characteristics. 

In tymphadenoma, or Hodgkin's disease, there is extreme anemia, 
though the excess of leucocytes present in leucocythemia is seldom 
reached and the cells are smaller. The glandular enlargement of 
lymphadenoma is an early and constant symptom, the spleen not being 
much enlarged. The cervical glands are the ones usually first involved. 



1 Thayer: loc. cit. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 697 



The duration of leucocythaemia is usually two or three years ; but 
some cases terminate in six months or even less, and some last six or 
seven years. The size of the spleen and the degree of oligocythaeinia 
appear to have no influence. Gowers states that the cases in which 
enlargement of the lymphatic glands is an early symptom run a course 
apparently much more acute than others, but he admits that the num- 
ber of such cases is comparatively small. 

Death results most frequently from gradual loss of strength. Hemor- 
rhage from various organs and surfaces is the immediate cause in many 
cases. It occurs in about three-fourths of the cases, and when not 
directly fatal increases the pre-existing asthenia. Diarrhoea and pul- 
monary complications are not infrequent causes of death. 

Splenic Anaemia. Splenic anaemia is a disease of the blood-making 
apparatus characterized by enlargement of the spleen and progressive 
anaemia, the special features of which are decided diminution of the 
number of red cells without marked increase of the white. 

The disease develops very gradually, and usually escapes observation 
until the spleen has attained considerable size. The anaemia appears to 
keep pace with the splenic enlargement, gradually increasing in intensity 
as the spleen enlarges. The clinical symptoms are those of anaemia — 
pallor, weakness, dyspnoea, palpitation. In the later stages of grave 
cases dropsies occur and hemorrhages, especially into the skin (petechiae 
and ecchymoses) and from the nose, are liable to occur. The hue of 
the skin is that of yellow wax. There is not usually much loss of flesh, 
but the loss of muscular power is extreme. Fever of an irregular type 
is a common symptom. Mental dulness and drowsiness may be present. 
Appetite and digestion are impaired and the bowels irregular. The urine 
is free from albumin. 

The red blood-cells are diminished in number, and may fall as low 
as 2,000,000 or 1,000,000. Nucleated cells are present and so are 
poikilocytes in severe cases. Leucocytosis is usually of moderate 
degree. 

Hodg-kin's Disease. Hodgkin's disease (pseudo-leukaemia, lymph- 
adenoma, or lymphatic anaemia) is a disease characterized by enlargement 
of the lymphatic glands throughout the body and of other adenoid 
tissues also; by progressive oligocythaemia without, in most cases, much 
increase of the leucocytes ; and by the development of lymphatic tumors 
in unusual situations. 

The disease is most frequent in the first half of life, three-fourths of 
the cases being in males. 

The first symptom noted is enlargement of the glands of the neck, 
sometimes of the inguinal, less frequently the axillary; rarely the tonsils 
are the first to be affected. The enlargement is painless and progressive, 
appearing first on one side of the neck and extending under the jaw to 
the opposite side. The tumors at first are distinct and movable under 
the skin. The swollen glands may remain in this condition indefinitely 
for months or years; but eventually they begin to enlarge very 
rapidly, lose their separate identity, and coalesce into large masses. 



698 



SPECIAL DIAGNOSIS. 



Other glands in remote parts, as the axilla and groin, retro-peritoneum, 
and arm, are affected. They may be soft and fluctuating or very dense 
and hard, but heat, tenderness, suppuration, aud other evidences of in- 
flammation are absent. 

The spleen becomes enlarged, and may reach very great size, but rarely 
attains the dimensions common in leucocythsemia. 

Other adenoid tissue in the intestine, tonsil, and posterior nares, and 
even the thymus, may enlarge and give rise to pressure symptoms. 

Fever is a very constant S3 T mptom, but the type is not constant. 

The onset of the disease may be marked by fever and constitutional 
symptoms, and the glandular enlargement appear later. On the other 
hand, in three cases reported by J. Dreschfeld, 1 all the patients enjoyed 
good health and were able to follow their work until a few weeks before 
death. In all, symptoms appeared suddenly with pain, weakness, pallor, 
loss of appetite, and pyrexia. 

Coincident with the rapid and extensive enlargement of the glands, 
ansemia becomes pronounced, and is accompanied with the usual symp- 
toms. Cough is often associated with the dyspnoea, aud in women men- 
struation may cease. 

In addition to the general symptoms there are numerous local ones 
due to pressure or impairment of function — cerebral ansemia from pres- 
sure on the carotids; cerebral congestion from pressure on the veins of 
the neck; disturbance of the heart from pressure on the pneumogastric; 
deafness; difficulty in deglutition and mastication, and pleural, perito- 
neal, and pericardial effusions. 

The most frequent complications are nephritis, fatty degeneration of 
the heart, pleurisy, and less frequently pneumonia and pericarditis. 

The duration of the disease is from six to eighteen months. Two- 
thirds of fifty fatal cases referred to by Gowers 2 ended in less than two 
years. It is difficult to determine accurately the beginning of the dis- 
ease; sometimes a long period of latency follows the early glandular 
swelling; sometimes a general anaemia precedes any noticeable swelling 
of the glands, and sometimes the disease runs an acute course, ending 
fatally in two or three months. 

Death results most frequently from exhaustion ; but pressure upon 
the trachea producing asphyxia is not uncommon, aud death has occurred 
from starvation, the result of occlusion by pressure of the oesophagus. 
The complications already mentioned are the immediate causes of death 
in other cases. 

Scrofulous enlargement of the glands presents the following points 
of difference: (1) Scrofula (tuberculosis) affects, as a rule, one group of 
glands, a local cause for whose enlargement is often present ; (2) the glands 
tend to soften, with the formation of cheesy pus, and they may be some- 
what painful ; (3) it affects children much more frequently than is true of 
Hodgkiu's disease ; (4) the persons affected exhibit other manifestations 
of so-called scrofula, particularly in the eyes, nose, skin, aud joints; (5) 
the blood changes, particularly the leucocytosis, do not reach the same 
intensity as in Hodgkiu's disease; (6) the submaxillary glands are more 

1 British Med. Journ., April 30, 1892. 

2 Reynolds' System of Medicine, Philadelphia, 1SS0, vol. iii. 549. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 699 



frequently the seat of scrofulous adenitis, whereas Hodgkin's disease 
affects particularly the glands of the anterior aud posterior cervical 
triangles. 

Leucocythcemia is distinguished by the great enlargement of the spleen, 
the enlargement of the liver, and the characteristic blood changes. 

Addison's Disease. Addison's disease is characterized by a gradual 
loss of strength without much loss of flesh ; by gastric uneasiness and 
occasional vomiting; feeble circulation ; and a bronze hue of the skin. 
The only fairly constant anatomical lesion is that of the supra-renal 
bodies. 

The disease occurs most frequently during the active period of life, 
from twenty to forty, and nearly twice as often in males as in females. 
It is thought by some to be tuberculous in nature ; some cases seem to 
have followed injuries. 

The disease begins insidiously with gradual and progressive loss ot 
strength. It becomes evident from the patient's languor, weariness on 
slight exertion, and inaptitude for mental effort that he is suffering with 
some exhausting disease. The appetite is impaired or lost, there is more 
or less discomfort at the epigastrium, and occasional vomiting. 

Perhaps at this time a close inspection may show some discoloration 
of the skin, but usually this appears later. By degrees the gastric 
symptoms become more prominent, and vomiting may be so common as 
to shorten life materially. The most characteristic symptom is the ex- 
treme prostration without any obvious cause. Any exertion requires 
great effort, and may induce fainting. Finally, the patient is unable to 
leave the bed. Dull pains in the head, back, and abdomen are not 
uncommon; neuralgic pains in the limbs maybe complained of; and 
Osier states that there is tenderness on pressure in the lumbar region in 
a considerable proportion of the cases. 

The pulse is extremely small and feeble ; in the later stages it may be 
absent at the wrist. 

The discoloration of the skin is the most striking symptom of the 
disease when it is well marked. Sometimes the whole body becomes of 
a walnut-juice color, a bronzing which is deeper in exposed surfaces, as 
the face, neck, aud hauds, and wherever there is naturally a deposit of 
pigment, as the axilla and the genitals. At times only portions of the 
body are discolored, in which case the dark hue shades off gradually into 
the normal hue of the skin. 

The pigmentation may extend to the mucous membranes of the mouth , 
eye, and vagina. Wilks 1 states that in all the cases which he has seen 
the scalp, finger-nails, soles of the feet, and palms of the hands escaped 
pigmentation. 

Nevertheless discoloration of the skin is not an essential symptom of 
the disease ; in some cases it is entirely absent. These cases, especially 
if associated with much vomiting, run a more acute course than the 
others, lasting only a few weeks. Such cases have been mistaken for 
typhus fever. 

1 Reynolds' System of Medicine, Phila., 1830, iii. 561. 



700 



SPECIAL DIAGNOSIS. 



The diagnostic symptoms are progressive asthenia, eauseless nausea 
and vomiting, and bronzing of the skin and mucous membranes. 

The duration of the disease is usually from six months to two years ; 
but some have lasted from six weeks to ten years, and others, as already 
stated, prove fatal in a few weeks. Death results usually from asthenia, 
but it may also occur suddenly from syncope, or in coma and convul- 
sions. 

The differential diagnosis is from (1) jaundice; (2) pigmentation 
occurring in abdominal tumors ; (3) pregnancy and chronic uterine dis- 
ease ; (4) melanotic cancer; (5) vagabond's disease; (6) leucoderma. 

Exophthalmic Goitre. Exophthalmic goitre, Graves' or Basedow's 
disease, is a disease characterized by (1) great rapidity of the heart's 
action ; (2) enlargement of the thyroid ; (3) prominence of the eyes ; 
(4) muscular tremor ; (5) vomiting and diarrhoea, chiefly the latter, 
without cause. 

It is far more frequent in women than in men. It may develop at 
any age, but is most common in early adult life. The particular cause 
is unknown, though it is probably located in the medulla. A neurotic 
heredity, exhausting disease, general debility, and ansemia are predis- 
posing causes, while sudden fright or shock is the most common 
exciting cause. 

Of the three classic symptoms, rapidity of the heart's action, with 
palpitation, enlargement of the thyroid, and prominence of the eyes 
(exophthalmos), the first is the essential symptom. It is also usually 
the earliest. Either enlargement of the thyroid or exophthalmos may 
be absent for months or years, and in some instances throughout the 
disease. 

1. Graves' disease begins slowly. Attacks of palpitation may recur 
at intervals for a long time before their true nature is suspected. In 
these attacks the behavior of the heart is much like that which occurs 
under the influence of fright or great excitement. The frequency may 
not be over 100 or 120 in the early attacks, the rate being normal in 
the intervals. In the later and severe attaks, however, the pulse beats 
160 or 180 or even 200. It is small and regular. The heart beats 
with increased force; the sounds are loud, sharp and clear, occasionally 
being heard several feet from the patient. In time the heart becomes 
hypertrophied and dilated, and there is often a loud basic systolic 
murmur. 

The larger arteries and even sometimes the smaller ones show the 
vascular disturbance by increased pulsation, sometimes with thrill. 

2. The thyroid is usually the next to become affected. It enlarges 
slowly from vascular dilatation, the swelling at first subsiding in the 
intervals between attacks, but subsequently persisting. The right lobe 
may be larger than the left. The enlargement is painless, soft, and 
compressible. It may pulsate with or without thrill, and over it can 
be heard haamic murmurs. 

3. Prominence of the eyes is the most conspicuous feature of w 7 ell- 
marked cases. Like enlargement of the thyroid it varies in degree, 
and rarely is wholly absent. The protrusion allows the white sclerotic 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 701 



to show above and below the cornea, giving the eyes an unnatural, 
startled, staring appearance. The protrusion may be so great that the 
eyelids cannot close ; more commonly they close, but when the eyeball 
is simply directed downward the upper eyelids do not follow, but 
remain spasmodically elevated or lag behind the movement of the eye- 
ball (Von Graefe's symptom). The eyeball may become inflamed and 
even slough from the undue exposure. 

In addition to these characteristic symptoms the patient loses flesh 
and strength, has moderate pyrexia of irregular type, suffers from 
impaired appetite, diarrhoea, and despondency. The diarrhoea is of the 
nervous type — increased peristalsis without local catarrh. Menstrua- 
tion is apt to be irregular or to cease. Tinnitus aurium, headache, and 
vertigo are not uncommon, and sometimes there is profuse sweating. 
Muscular tremor, occurring on voluntary movement, is frequently 
observed, and, with diarrhoea, is almost as common as the three primary 
symptoms. 

Graves' disease, as a rule, runs a chronic course, lasting for years. 
A few cases that have run an acute course of a few weeks, some 
ending in recovery and some in death, have, however, been reported. 
Moreover, there may be recurring attacks with apparent recovery in 
the intervals. Recovery is thought to occur in about one-fourth of the 
cases. Gowers states that it is most frequent in the cases that develop 
rapidly and in which the cardiac symptoms preponderate over those in 
the neck and eyes, and that complete recovery is very rare when there 
is much enlargement of the thyroid and much prominence of the 
eyes. 

Death results from gradual weakening of the heart and its direct and 
indirect effects. It may be hastened also by uncontrollable diarrhoea, 
acute mania, and epilepsy. The disease may also be complicated with 
hemorrhages, and these be the immediate cause of death. 

Parasites in the Blood. The principal vegetable parasites are : (1) 
Spirilla of relapsing fever ; (2) tubercle bacilli ; (3) anthrax bacilli ; 
(4) bacilli of glanders ; (5) plasmodia of malaria ; (6) typhoid bacilli. 

The animal parasites are : (1) Filaria sanguinis hominis ; (2) distoma 
haematobium. 

The Spirilla of Relapsing Fever. These are slender, thread- 
like organisms of spiral shape, seven or eight times the length of a 
red blood-cell, with a very lively forward movement in the direction 
of its long axis. Under a low power the blood may appear to be in 
motion, as the result of their movement. They have so far been found 
only in the height of the febrile attacks ; but Von Jaksch states that 
so long as a relapse is to be feared the blood contains peculiar highly 
refracting bodies resembling diplococci, which are especially numerous 
before the attack ; in some cases it has seemed to him that these diplo- 
cocci at the very beginning of an attack develop into short, thick rods, 
from which the spirilla develop; they may, therefore, prove to be 
spores. Staining is unnecessary for the detection of spirilla, but 
cover-glass preparations of the blood can be stained with fuchsin or 
gentian-violet. 



702 



SPECIAL DIAGNOSIS. 



Tubercle Bacilli. Tubercle bacilli have been found in the blood 
in miliary tuberculosis. Cover-glass preparations of the blood are made 
and stained as in the case of sputum (which see). 

Plasmodia of Malaria. The plasmodia of malaria were first 
pointed out by Laveran. They have been studied in Italy, especially 
by Marchiafava and Golgi, and in this country by Councilman, Osier, 
and Dock. Minute amoeboid bodies are found first in the red corpuscles. 
These become pigmented with altered haemoglobin, and grow until they 
fill nearly the whole of the cell, the pigment being arranged especially 
in a peripheral ring. Later, the amoeboid bodies become spherical and 



Fig. 130. 




Malarial plasmodia. (Reproduced from colored plate.) Dry preparation. Stained with eosin- 
methyl-blue (one after the other), x 1600. To the right above, a normal rose-red stained red 
blood-cell, beneath it two such red-stained cells with bluish contained bodies, sprinkled with pig- 
ment, on one cell a colorless vacuole ; next the same, bluish-stained parasite ; farther away several 
of Laveran's crescents of clear violet or bluish color with reddish edge, which is continued in a 
fine line connecting both ends of the crescent, and which forms the remainder of the red blood- 
corpuscle. The pigment of dirty brownish-black color is constantly arranged in the centre of the 
crescent as a heap of fine granules. At the lower edge of the field is a colorless erythrocyst con- 
taining no haemoglobin, and only containing a few scattered pigment granules. To the left a 
large mononuclear white blood-cell with large nucleus of bluish color. (H. Rieder.) 

transparent, the pigment collecting in the centre. Sporulation now 
occurs and a fresh crop of small, rounded parasites appears, to begin 
the same cycle over again in fresh corpuscles. Golgi maintains that 
in tertian malarial fever the period between invasion of the corpuscles 
aud the sporulation is two days ; in quartan, three days, the difference 
in cycle being due to a difference in the parasites. 

The onset of the fever corresponds in time to the division of the 
parasites. 

The crescentic form described by Laveran is said to be more common 
in the irregular forms of malarial fever. Caualis 1 says that it only 
makes its appearance several days after the first access of fever. It is 



1 Fortschritte der Medicin, 1890, viii. Nos. 8 and 9. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 703 



somewhat longer than a red blood-cell, and the pigment tends to collect 
in a focus about the middle of the parasite. Subsequently they become 
oval and divide into eight or more daughter cells. 

Another- form with flagella is occasionally found. Councilman says 
it is most common in blood drawn directly from the spleen. 

The plasmodium of malaria may be stained as follows : Cover-glass 
preparations of the blood are dried in the air and fixed by immersion 
for twenty minutes or half au hour in a mixture of equal parts of alcohol 
and ether. They are then stained for ten to fifteen minutes in a solu- 
tion of three ounces of strong aqueous solution of methyl-blue to which 
a few drops of absolute alcohol and then seven and a half grains of eosin 



Fro. 131. 




Malarial Plasmodia. (Reproduced from colored plate.) Same preparation as preceding ; same 
amplification. To the right two normal red blood-cells with central depression. In addition, several 
others with bluish contained bodies and pigment-sprinkled cells, which show the endogenous de- 
velopment of the Plasmodia. Besides, two of Laveran's bodies, one exhibiting a delicate little 
basket. Near the centre a polynuclear white cell with bluish nuclei and red granulation. 

(H. B.IEDER.) 

dissolved in water are added. The cover-glasses are then washed in 
water, dried, and are then ready for mounting. The red blood-cells are 
stained rose, the nuclei of leucocytes a deep dark-blue, and any plas- 
modia a delicate sky-blue. 1 (See Malarial Fever.) 

Anthrax Bacilli. Anthrax bacilli are found in small numbers 
in human beings with anthrax, especially in blood from the spleen. 
They are from 5 to 12 ^ long and 1 p broad, immovable rods, appear- 
ing as though divided into sections. They can be seen without staining, 
but the bacilli readily take the basic aniline dyes. 

Bacilli of Glanders. These are occasionally found in human 
blood. They consist of rods 2 to 3 ^ long and 0.3 to 0.4 fi broad, 
frequently having spores on the ends- Loffler's staining method is 
recommended for their detection. 



1 Hochsinger : Wiener med. Presse, 1891, No. 17. 



704 



SPECIAL DIAGNOSIS. 



The Filaria Sanguinis Hominis. Filarise are found in the blood 
and lymph of persons who live in the tropics, and in a few instances have 
been found in native Americans (John Guite>as). They have a blunt, 
rounded head with a tongue-like process and a long, pointed tail. They 
produce lymphatic swellings (particularly of the scrotum), chyluria, and 
hematuria. 

Fig. 132. 




Filaria sanguinis hominis— embryonic form. (Lewis.) 



Patrick Mauson 1 says the following are the commonest mistakes in 
the search for filarise : (1) The use of too high a magnifying power ; 
(2) employing too strong an illumination; (3) searching unmethodically 
and in too small a quantity of blood ; and (4) looking for filarise in 
blood drawn from the body at a time when the particular species sought 
for is normally absent from the circulation. He describes three forms: 
filaria sanguinis hominis nocturna (the ordinary form) ; filaria sanguinis 
hominis diurna, and perstans. The last appears to be the one asso- 
ciated with the production of the disease known on the west coast 
of Africa as " sleeping sickness." He prefers dry preparations of the 
blood, stained with a \ per cent, eosin solution or a weak solution of 
fuchsin (one drop of the saturated alcoholic solution to an ounce of 
water). If a thin film of blood, before it has fully dried, be held over 
acetic acid so as to imbibe the fumes, and be then stained in a J per 
cent, solution of eosin, the blood is stained, but any filarise remain pearly 
white. 

1 Trans. Seventh International Congress of Hygiene and Demography, vol. i. p. 93. 



CHAPTEK IX. 



CONSTITUTIONAL DISEASES. 

The modern enthusiastic and voluminous labor in morbid anatomy 
and histology and in bacteriology has put into the background for the 
time being affections which, although they possess a distinct entity, are 
more vague and recondite. The occurrence of morbid processes behind 
which as a causal factor a constitutional state exists, as hemorrhages in 
hsernophilia or gastro-intestinal catarrh in rhachitis, must not be for- 
gotten. The occurrence of abnormal phenomena, with or without a 
cognizable morbid process, should always call for the consideration of a 
possible general condition, or diathesis, as it was formerly termed, before 
the diagnosis is fully concluded. In a case of fever, for instance, we 
aim too often to determine the infection and its character, whereas an 
infective process may not be present, the fever being due to other, 
possibly constitutional, causes. 

Advance in the science of medicine has transferred anaemia and 
chlorosis, formerly considered to be constitutional diseases, to the domain 
of blood diseases. Syphilis, tuberculosis, and probably cancer, are now 
known to be infectious diseases. The field has been narrowed ; doubtless 
it will become extinct as our knowledge of constitutional affections 
becomes more precise. 

Rheumatic Fever. 

An acute, general, febrile, non-contagious disease, characterized by 
specific inflammation of the joints and their contiguous structures, 
hence called acute articular rheumatism. It is further characterized by 
a tendency of the inflammation to involve the larger joints successively, 
to skip from one joint to another, and to be associated with endo- and 
pericarditis. 

The predisposing causes of rheumatic fever are heredity, which is 
operative in 25 or 30 per cent, of the cases ; age — 81 per cent, of first 
attacks occur between the eleventh and thirtieth years (Pye-Smith) ; 
sex, in childhood girls are more frequently affected than boys, but after 
that period sex appears to have no influence. Polyarticular inflamma- 
tions, sometimes rheumatic in nature, are met with during convalescence 
from scarlatina and dysentery. They also occur in association with the 
puerperal state and gonorrhoea, in which they are probably pysernic. 
The nature of the polyarthritis which occurs in connection with dengue 
and haemophilia is obscure. 

Damp, changeable weather appears to be more potent as an exciting 
cause than very cold weather. It is especially effective when the system 
is depressed from any cause. The disease occurs, however, at all seasous 
and in all climates. 



706 



SPECIAL DIAGNOSIS. 



Symptoms. The onset of the disease is not characterized by constant 
symptoms. Sometimes the fever and joint inflammation are preceded a day 
or two by debility, wandering pains in the joints or muscles, and loss of 
appetite. In other cases there is a chill or repeated attacks of chilliness, 
followed in a day or two by fever and inflammation of the joints. In 
rare cases the onset may be followed not by inflammation of the joints, 
but by that of the serous membranes, particularly those of the heart 
and its sac. 

The temperature may rise a day or two before there are any joint 
symptoms, or fever and arthritis may begin almost simultaneously. 
The temperature rises rapidly to 102°, 103°, or 104 F., and one or more of 
the larger joints, generally the knee and aukle, become painful, tender, 
swollen, and hot. There may be great pain on motion before there is 
evident swelling or much local tenderness. The pain varies from dis- 
comfort to the most excruciating suffering. It is always aggravated by 
motion or pressure and is at times so exquisite that the slightest touch, 
the weight of bed-clothing or the jar of the bed from a heavy step in 
the room makes the patient cry out. It may extend beyond the joint 
to neighboring tendons and nerves. The swelling likewise varies 
greatly ; sometimes there is only slight puffiness with increased distinct- 
ness of the cutaneous veins, increased heat in the part, but no general 
redness ; in other cases there is considerable swelling about the joiut 
so that the bony prominences are obliterated, the surface being tense, 
red, and very hot to the touch. There is often also effusion into the 
joint. Swelling is most marked in the wrist and ankle, and less so in the 
shoulders, hips, elbows, and knees. 

Multiplicity of joints affected. A characteristic peculiarity of rheuma- 
tism is its tendency to involve one joint after another. One or several 
joints may be affected at first ; it is very common for the right ankle to be 
affected, and then in a short time the opposite ankle, followed by the left 
knee and right knee, and so on with other joints. The inflammation 
usually lasts in each joint from two to four days. The process may sub- 
side in one articulation and begin in another with startling rapidity. 

At one visit the right ankle may be swollen, hot, and unbearably 
painful, and on the next day the patient be found comfortable as to the 
first joint but suffering acute pain in the right knee or left ankle. 

The pulse in the early stage of rheumatism is moderately accelerated 
(90 to 110) ; it is regular, of good volume, often bounding, and some- 
times hard. The urine is scanty, high colored, abnormally acid, and 
deposits on cooling a copious precipitate of urates, resembling red sand 
in appearance. The skin does not feel so hot as one would expect from 
the temperature. It is continually covered with a copious, acid, and 
somewhat pungent perspiration. Nervous symptoms are not marked. 
There may, however, be slight nocturnal delirium. Sleeplessness from 
pain is very common. 

The temperature in rheumatic fever is not usually very high ; it is 
much oftener under 103° than over it. In rare cases, however, espe- 
cially when the fever is complicated with pericarditis, pneumonia, or 
some disturbance of the heat-regulating apparatus, the temperature may 
attain the extraordinary range of 106-112° F. Such high tempera- 



CONSTITUTIONAL DISEASES. 



707 



tures may occur suddenly or gradually, and are sometimes attended 
with marked brain symptoms (so-called cerebral rheumatism). 

Endocarditis and pericarditis may occur at any period of rheumatic 
fever ; they may even precede any joint-inflammation. They are most 
common, however, in the first two weeks of the disease. The younger 
the patient and the more severe the attack the greater the liability to 
heart complications. They occur in about one-fourth of all cases. 
Endocarditis is most common ; often it is the only lesion, but sometimes it 
is associated with pericarditis, and more rarely with myocarditis. These 
complications usually give rise to no symptoms at first. Hence the 
heart should be examined daily. The occurrence of a sense of con- 
striction in the praecordia or pit of the stomach, an anxious expression 
of the face with pallor, a change in the frequency but especially in 
the rhythm of the pulse, and of cough or dyspnoea, should attract 
attention to the heart. The physical signs of the respective lesions have 
been described fully under Diseases of the Heart. 

The establishment of convalescence from rheumatic fever is marked 
by cleaning of the tongue, which also becomes less red, and the secretion 
of a large volume of urine, which still remains of high specific gravity. 
The fever subsides gradually, the joints cease to be red, swollen, and 
tender, the acid sweats lessen, aud the appetite improves. In proportion 
to the duration of the case and its severity the patient is left with debility 
and marked anaemia, both red cells and haemoglobin being diminished. 
In ansemic cases a hsemic murmur may be heard over the base of the 
heart. In some cases acute dilatation has been observed, and a 
tricuspid murmur. 

Complications and Sequels. Apart from heart complications 
which have been mentioned already, pleuritis, pneumonia, and bronchitis 
occur in from 10 to 15 per cent, of the cases. They are frequently 
bilateral, and are very much more common in rheumatic fever with 
pericarditis or endocarditis than in simple rheumatic fever. Moreover, 
the pulmonary complications are frequently latent, and would be over- 
looked but for daily physical examination of the chest. Again, they 
may develop with great suddenness, and what appears to be a full- 
blown pneumonia may, on the other hand, subside suddenly as a fresh 
joint is affected. They behave more like sudden active congestions 
than true pneumonias. Rheumatic pleurisies are characteristized by 
the rapidity with which effusion takes place, the persistence of pain in 
the side during effusion, the tendency to involve both sides in succession, 
the readiness with which the effusion is absorbed, and their acute course. 

Nervous System. The most common complications on the part of 
the nervous system are delirium, which is generally associated with 
insomnia and hyperpyrexia, but the latter is not constant. These 
brain symptoms generally appear in the second week of illness, and 
about the time of convalescence, or while the joints are still inflamed. 
The delirium may be low and muttering, accompanied by ataxic symp- 
toms or even with tremors and spasms of muscles ; or it may be furious. 
In favorable cases a deep sleep ushers in recovery, or in unfavorable 
cases the delirium persists with adynamia, the patient dying in collapse 
or coma, preceded or not by convulsions. 



708 



SPECIAL DIAGNOSIS. 



Chorea sometimes occurs as a complication, but it is more common iu 
mild cases in children as a sequel. Cerebral meningitis occurs rarely, 
especially when there is ulcerative endocarditis. Cerebral embolism is 
another rare complication. 

Various spinal symptoms occur in some cases, at times with and at 
times without demonstrable lesion of the cord or its membranes. 
Tetanus, myelitis, and spinal meningitis may all be simulated. Per- 
haps these symptoms are due to high temperature; but very high 
temperatures are met with without the occurrence of any cerebral or 
spinal symptoms. 

Nephritis is rare, but sometimes hemorrhage into the kidney occurs 
with its usual symptoms. Peritonitis is extremely rare. 

Various erythematous skin eruptions are seen from time to time, and 
occasionally purpura. Subcutaneous nodosities have been described by 
several writers. They are attached to the tendons, fascia, and peri- 
osteum, and are most frequent on the back of the elbow, the ankles, 
and patella. They are painless and may occur in any form of rheuma- 
tism. 

The duration of the disease varies from a week to six or eight weeks, 
depending upon the severity of the attack, the presence or absence of 
complications, and the treatment. When the joint symptoms are pro- 
nounced and the fever continuous, the course is likely to be shorter. 
When the symptoms are milder, recovery may be retarded by repeated 
relapses. 

Diagnosis. Rheumatic fever is distinguished from gout by the pro- 
fuse acid and acrid sweating, the tendency to involve a number of joints 
and particularly the larger ones, by the greater intensity of constitu- 
tional symptoms, by the absence of uric acid from the blood, and the 
great liability to heart complications. 

It is distinguished from pycemia by the wandering character of the 
inflammation; the acid sweats; the absence of any antecedent condi- 
tion liable to develop purulent foci — such as injuries, abscesses, or 
specific eruptive fever ; the absence of chills, and the fact that in rheu- 
matic fever the sweats are constant, whereas in pyaemia they follow a 
fall in temperature. Cutaneous abscesses do not occur in rheumatism, 
and upon its subsidence the joint's usefulness is not impaired. 

Acute synovitis resembles rheumatic fever in there being pain, tender- 
ness, and swelling of a joint. Usually, however, but one joint is in- 
volved, and there is a history of exposure to cold or of injury. The 
effusion is limited to the joint largely, is frequently abundant, and 
fluctuation can easily be detected. The constitutional symptoms are 
much less marked than in rheumatism. 

Milk-leg or phlegmasia alba dolens differs from rheumatism in its 
occurring generally in women after confinement, or as a complication 
or sequel of fever, as typhoid fever. Usually only one leg is affected, 
or part of the leg, especially the calf. This becomes tense, tender, 
uniformly swollen, and the seat of great pain. The leg is moved with 
much difficulty. The femoral vein may be found to be knotted and 
tender. There is almost always evidence of antecedent disease. 

Acute jwiostitis when close to a joint simulates rheumatism. But 



CONSTITUTIONAL DISEASES. 



709 



the tenderness and heat are not in the joint itself, but are superficial 
and associated with less swelling. There may be detected by palpation 
some effusion under the periosteum. When this is purulent or there is 
also ostitis there may be chills and pysemic symptoms. 

The articular symptoms of glanders are to be distinguished by the 
occupation of the patient, the mode of onset, the associated symptoms, 
especially one or more pustules, and the fact that the painful joints are 
not so apt to be swollen and red as in rheumatic fever. 

In syphilis there frequently occur joint pains, whose character is 
made out by the fact that the joints are not inflamed, the pain is much 
worse, or only occurs at night, and by the history of the patient and 
the therapeutic test. 

In diseases of the brain and spinal cord joint inflammations occur of 
trophic origin. They are distinguished by the coexistence of some 
lesion of brain or cord, with hemiplegia or other palsy, and of other 
trophic changes, such as bedsores, atrophied muscles, loss or excessive 
growth of hair, shiny skin, and defective growth of the nails. 

Subacute Articular Rheumatism. 

In some instances the joint inflammation is less severe and is accom- 
panied by only slight fever. One or more joints may be affected. It 
differs from the ordinary form in being milder in degree and more per- 
sistent, lasting sometimes for months. It is generally subacute from 
the beginning, but may be the type present in those who have had 
several attacks of rheumatic fever and have been left in a very 
sensitive condition. Rheumatic fever is usually subacute in children, 
and often only one joint is involved. Cardiac complications are more 
frequent than in adults, and chorea may occur as a sequel. Erythema 
nodosum and subcutaneous nodosities are more common in children. 

Chronic Articular Rheumatism. In this form the patient has 
pain and stiffness in one or more joints, or in the contiguous tissues. The 
joiuts most frequently affected are the shoulder and knee. The pain is 
more or less constant, but worse in damp weather or on the approach of 
a storm, worse also frequently at night. Conversely, it is better in 
warm, dry weather. There is not much, if any, tenderness, and rarely 
any swelling or elevation of temperature. The joints very frequently 
crack and grate on motion. In the intervals of attacks there is no 
impairment of the usefulness of the joints. In very chronic cases there 
may be some atrophy of muscles and permanent stiffness, even fibrous 
ankylosis. 

In some cases there are repeated attacks of subacute articular rheuma- 
tism accompanied with the usual symptoms and joint effusions. 

The duration of the disease is indefinite, but it usually lasts for 
months or years ; the patient becomes much debilitated from pain and 
stiffness. There is little risk to life, and cardiac complications are 
uncommon. It is distinguished from chronic gout by the fact that there 
is no special tendency to involve the great toe, by the absence of the 
deformities resulting from gout, and of deposits of urate of soda in the 
ears, fingers, and around the joints. 



710 



SPECIAL DIAGNOSIS. 



Muscular Rheumatism. 

In this variety of rheumatism there is pain in the affected muscles, 
which often comes on suddenly in the night, or is .first noticed when 
the patient attempts to rise in the morning. The pain when the 
patient is at rest may be inconsiderable, rarely amounting to more 
than a dull, aching, sore feeling; on attempting to move, to bend, or 
twist, or straighten himself, however, the patient catches himself sud- 
denly on account of the agonizing tearing or burning pain. When the 
muscles are relaxed the patient is fairly comfortable. Sudden move- 
ment is the most painful. The affected muscles are tender to touch 
and to sharp blows. 

Muscular rheumatism may be acute or chronic. In the latter the 
symptoms are very like those of chronic articular rheumatism, except 
that the muscles and not the joints are affected. There is the same 
proneness to recur in unfavorable weather and cold, damp seasons. 

The disease receives different names according to the muscles affected. 
The most common sub-varieties are : lumbago, in which the muscles of 
the small of the back are affected ; pleurodynia, in which the intercostal 
muscles suffer; and torticollis, in which the sterno-mastoid and trapezius 
are painfully contracted. 

In lumbago the patient holds himself rigidly and is unwilling to 
rotate the trunk upon the vertebrae. Often the most comfortable 
position is that in which he sits and bends slightly forward over another 
chair. Motion is painful, but pressure is not. Fever is absent. There 
is a history of repeated attacks, or of exposure, such as lying upon 
damp ground. It needs to be distinguished from disease of the spinal 
membranes, from disease of the vertebrae, aneurism, abdominal abscess, 
and diseases of the uterus and ovaries. The diagnosis of rheumatism 
is arrived at by exclusion. 

In pleurodynia there is usually tenderness upon pressure as well as 
upon motion and deep inspiration. The pain is of the same sore, burn- 
ing character, aggravated by coughing and sneezing. The patient seems 
to breathe as little as possible, and often bends over toward the affected 
side to lessen the motion. It is distinguished from pleurisy by the ab- 
sence of fever, cough, and, above all, of friction sounds. In intercostal 
neuralgia there are painful points upon pressure, whereas in pleurodynia, 
firm pressure is grateful, though tapping is painful. 

In torticollis the head is drawn to one side and fixed in that position. 
The sterno-mastoid especially is rigid and tender on pinching. In 
spinal affections the head is retracted, and there are antecedent symptoms, 
as headache and darting pains with fever. 

Rheumatoid Arthritis. 

Rheumatoid arthritis or rheumatic gout is an affection characterized 
by acute or chronic inflammation of the joints, of progressive character, 
and resulting in deformities. It is accompanied with very little fever, 
and occurs apart from any known systemic disease. 

It may be acute or chronic. The acute form differs but little in its 



CONSTITUTIONAL DISEASES. 



711 



manifestations from acute rheumatic fever. Several joints are enlarged, 
tender, and painful. Constitutional symptoms, such as fever, loss of 
appetite, frequent pulse, thirst, furred tongue, occur as in rheumatism. 
Profuse acid sweats, however, are absent, and so is the tendency to serous 
inflammations. Moreover, while the larger joints, as in rheumatism, 
may be affected, the smaller ones also, especially of the fingers and toes, 
are inflamed and often the seat of serous effusions. Furthermore, the 
inflammation persists in the affected joints and does not jump from one 
to another. Instead of disappearing in a few weeks, it drags on for a 
much longer time. The pain subsides but the swelling persists, and 
permanent deformity results in at least some of the joints. The muscles 
of the arms and legs waste and are affected with painful spasms. 

The disease is most common in young women exhausted by repeated 
pregnancies or prolonged lactation, and is favored by poverty, privation, 
and cold. 

The chronic form is much more common. It also attacks most fre- 
quently young women who are exhausted or subject to great fatigue. 
There is pain, numbness, or formication in a joint, as the knee. The joint 
becomes tender, painful, and may be slightly swollen. This subsides after 
a while, but sooner or later the same joint or another one becomes 
affected, the process is persistent, one joint after another is attacked, and 
gradually all the joints may become greatly distorted, enlarged, and the 
seat of contractions. There may be no impairment of general health, 
or, at most, only dyspeptic symptoms. The progress is interrupted by 
remissions from time to time. Pain may be severe and subject to 
nocturnal exacerbations. The shape of the joints is altered by the effu- 
sion into the joints and adjacent bursas, by thickening of the tissues 
around the joints, growths of new bone on the joint extremity of the 
bones, absorption of the articular cartilages and growths of new carti- 
lage in the synovial sheaths, relaxation of the ligaments, muscular con- 
tractures, and luxation of the joints. The joints crack and creak like 
rusty hinges, are sore and stiff, and the attached muscles are affected with 
painful cramps. 

Great enlargement of the joints at times occurs from the causes 
already mentioned and from infiltration of the overlying tissues. The 
enlargement is rendered more conspicuous by the atrophy of adjacent 
muscles. 

In addition to the articular symptoms, other phenomena attend the 
process. One of the more common is increased frequency of the pulse. 
Although the patient is afebrile, the average pulse-rate is 100 to 120, or 
even more. Moreover, the pulse is soft and compressible, in contra- 
distinction to the pulse of gout or rheumatism. It is worth notiug that 
a return to the normal frequency is a sign that the process of the disease 
is arrested, although the joint lesions remain. 

The skin is characteristic. It is soft and often much freckled, while 
the complexion is fair. C. T. Griffiths has observed the pigmentary 
cutaneous changes, along with neural symptoms, prior to the joint mani- 
festations, and describes two forms: a diffuse melasmic discoloration, 
and dark -brown spots resembling moles, but not raised. Moisture of 
the skin with clamminess is common. It is limited to the palms of the 



712 



SPECIAL DIAGNOSIS. 



bauds, or may occur iu the distribution of certain nerves. The sweats 
are uot acid ; they are usually local, but may be profuse. Pain inde- 
pendent of the joint lesion is due to neuritis, and may precede the joint 
trouble. It is not merely confined to the nerve-trunks, but the distribu- 
tion in muscles, as the base of the thumb. Numbness and tingling are 
often present. 

The progress of the disease is pretty steadily worse. In extreme 
cases not only are the limbs crippled, deformed, and helpless, but there 
is fixation of the cervical spine and of the articulations of the jaw, so 
that the patient cannot move the head or masticate food. 

The following describes the characteristic deformity of the hand : 
The first phalanx of the fingers is either flexed upon the metacarpus or 
extended, and the terminal phalanx in like manner is either markedly 
flexed or extended upon the second, or these two phalanges are kept at 
a straight line, while the first phalanx is, as usual, decidedly flexed upon 
the metacarpus. The hand is pronated and the fingers turn toward the 
ulnar side (Palmer Howard, and Charcot). (See page 127.) 

The foot is abducted and flattened and the great toe abducted across 
and above the other toes. Rarely it may be beneath the other toes. 
The metatarso-phalangeal joint is enlarged. 

A variety of the disease is sometimes met with, chiefly in old persons 
(senile arthritis), in which the tendency is to involve one or two joints, 
particularly the hip, or hip and knee. It is of slow progress and is 
otherwise attended with the same deformities as the usual polyarticular 
form. 

Rheumatoid arthritis is distinguished from gout by the absence of 
heredity and by its development under the exhausting influences of 
repeated pregnancies, lactation, poverty, and malnutrition. Rheuma- 
toid arthritis is progressive, with occasional remissions ; gout occurs in 
successive attacks, with intermissions. Uric acid is absent from the 
blood in the former and is present in gout. Rheumatoid arthritis in the 
vast majority of cases is subacute or chronic. The acute form is distin- 
guished from acute gout by the duration of the paroxysm and the 
absence of intermissions ; by there being less heat, swelling, and redness 
of the joints, and less infiltration of the soft parts ; by the fact that 
large and small joints are involved, and that there is no special tendency 
to inflammation of the great toe. 

From chronic gout rheumatoid arthritis is distinguished by the 
absence of hereditary predisposition, of repeated acute attacks, and 
of the causes of gouty paroxysms — indulgence in sugars, acids, 
malt liquors, etc. Moreover, rheumatoid arthritis most frequently 
begins in the hands, and is symmetrical and bilateral. Gout has a 
predilection for the great toe, and is unilateral. Again, gout attacks 
well-fed males most frequently after the age of thirty, while rheu- 
matoid arthritis tends to attack women under the depressing influ- 
ences already mentioned. It may, however, occur in both sexes, and 
even be associated with gout. 

Rheumatic fiver is distinguished from acute rheumatoid arthritis by 
its tendency to involve the larger joints, its erratic course, acid sweats, 
and heavy deposits of urates from the urine, its shorter course, its ten- 



CONSTITUTIONAL DISEASES. 



713 



dency to heart complications, and its subsidence without impairment of 
the usefulness of the joints. 

Chronic articular rheumatism is distinguished by the preceding his- 
tory, the tendency to seasonal exacerbations, by its involving fewer 
joints, and not being so symmetrical in the joints affected. It does not 
produce as great deformity as is common in rheumatoid arthritis, nor is 
it so likely to affect the vertebrae and jaws. The existence of valvular 
heart disease or a history of antecedent chorea is in favor of rheuma- 
tism. 

The joint affections of locomotor ataxia are distinguished by the 
associated symptoms of incoordination and absent knee-jerk, by their 
sudden onset without pain or fever, by the occurrence of large effusion 
into the joint with subsequent disorganization, fractures, and disloca- 
tions. 

Gonorrheal arthritis is distinguished by the history of gonorrhoea or 
the existence of a discharge from the urethra, by the tendency of the 
disease to attack the larger joints, particularly the knee or shoulder, and 
to become fixed in one, not wandering from one to another. The affected 
joint suffers effusion, and the synovial membranes and bursse are 
inflamed. The process is very chronic, but indolent, and the heart does 
not become affected. 

Gout. 

A disease characterized by specific arthritis, associated with uric acid 
in the blood and the deposit of urate of soda in the joints, or manifesting 
itself as a diathesis in which occur inflammations of non-articular tis- 
sues and various disturbances of functions of organs, the blood also 
containing uric acid. 

Gout is common in Europe, particularly in England, but in its artic- 
ular form is rare in this country. There is an hereditary predisposition 
in from 50 to 60 per cent, of the cases. It results from overeating of 
rich foods and the drinking of malt liquors, associated with deficient 
exercise and excretion. Garrod has called attention to its association 
with lead-poisoning. Paroxysms are induced by indiscretions in eating 
or drinking, by nervous shock or great mental strain, by exposure to 
cold or injury, or by overwork and sexual excesses. 

The characteristic phenomena of gout are preceded for a variable 
time by acid flatulent dyspepsia, colicky pains in the stomach and bowel, 
constipation alternating with diarrhoea, and scanty, heavily loaded 
urine. Accompanying these dyspeptic symptoms often are impairment 
of physical and mental vigor, irritability of temper, and hypochondri- 
asis. 

In other cases the premonitory symptoms are palpitation of the heart,, 
or dyspnoea resembling asthma, or various nervous symptoms, as 
drowsiness, insomnia, or headache. 

In acute articular gout the onset is often sudden, especially in the first 
attack. The patient may go to bed in apparent health but be waked 
up early in the morning with a feeling of discomfort or uneasiness, 
usually in the great toe. In some cases the pain is agonizing from the 
first. The patient finds he is unable to step upon the foot without 



714 



SPECIAL DIAGNOSIS. 



torturing pain. The ball of the great toe is hot, swollen, red, and 
exquisitely tender, resentful of the slightest touch or jar of the bed. 
The veins are swollen and the joint stiff. There are slight fever, per- 
haps chilliness, thirst, coated tongue, constipation, scanty, high-colored 
urine depositing urates on cooling ; the skin is warmer than normal and 
there is slight perspiration. The pain "usually abates during the day 
and exacerbates at night, being aggravated by motion and with painful 
muscular cramps. By the end of the first day or two the swelling 
increases and the pain lessens, owing to diminished tension of the part. 
Pain is still great, however, on motion, and without treatment may 
continue for a week or two ; under treatment the paroxysm subsides in 
four or five days. 

Both great toes may be attacked in the first seizure, more often alter- 
nately than simultaneously, and sometimes other joints than that of the 
toe are affected. 

With the subsidence of an attack the urine contains a larger quantity 
of uric acid, and the patient feels in better health and spirits than for 
some time. A second attack may be postponed for several years, but 
usually after that the intervals between them steadily lessen, until an 
attack recurs every few weeks or months, and the patient may be 
scarcely ever free from it. Other joints than the toes, particularly those 
of the fingers, become involved in subsequent attacks. 

Chronic gout results from repeated acute attacks. It is characterized 
by deformity of the affected joints, around which are deposited chalk- 
stones (tophi) of urate of soda. Similar deposits occur in the helix of 
the ear. The first appearance is that of a clear vesicle under the skin, 
which subsequently becomes chalky white and solid. The deposits of 
urate of soda occur not only in the cartilages of the joints, but in the 
ligaments and bursse also, resulting in great impairment of motion and 
deformity. u In extreme cases an appearance is presented by the hand 
very closely resembling a bundle of French carrots with their heads for- 
ward, the nails appearing to take the place of the stalks" (Garrod). 

Gouty abscesses consist of collections of liquid and solid urate of soda, 
which discharge, with or without the presence of pus, through the skin. 
A patient may have a number of them with but very little impairment of 
the general health. They may even act as a helpful vent to the system. 

Retrocedent gout is the name applied to the development of some acute 
internal affection upon the sudden suppression by cold or otherwise of 
an arthritis. Mania at times develops in this way. 

Gout attacks the nervous system, causing headache, delirium, and 
sometimes apoplexy, apoplectiform seizures, epilepsy, mania, various 
neuralgias, and spinal symptoms. 

It also affects the heart and bloodvessels, causing valvulitis and chronic 
arteritis. 

The symptoms on the part of the digestive organs have been men- 
tioned already. They are often premonitory of an attack. 

The kidneys may be affected, causing typical contracted kidney, or 
there may be chronic cystitis and urethritis. 

The shin gives evidence of its presence particularly in the form of 
psoriasis and eczema. 



CONSTITUTIONAL DISEASES. 



715 



Rhachitis. 

Rhachitis is a constitutional affection characterized by changes in the 
bones which lead to alterations in their shape and outline. It is usually 
developed in childhood, and is most common in children in bad hygienic 
surroundings, who have lived upon a starchy diet and have taken cow's 
milk for too long a period of time. A child that has been nursed 
during pregnancy is liable to have the disease. 

The appearance of the face and the changes in the bones have been 
previously described (see page 76). 

In addition to changes in the bones a child presents other evidences 
of defective nutrition. There is marked pallor; the muscles are flabby; 
the child is feeble, and the weak muscles give rise to an inaction which 
resembles paralysis. 

The disease usually progresses slowly, and is eminently chronic. A 
form is seen, however, in which the progress of the symptoms is more 
acute. With some gastro-intestinal disturbances there is mild fever, 
considerable weakness, and great restlessness. Sleep is disturbed, and 
pain is complained of if the child is of an age to make such complaint. 
Soreness of the body is observed on handling the child ; and of its own 
accord, on account of the pain and soreness, the customary movements are 
withheld. The child lies on its back and shrinks from any attempts 
to disturb it. The pain is not only caused by handling of the muscles, 
but the bones are also sore and tender. Sometimes the most marked 
manifestations of the more acute forms are the gastro-intestinal symp- 
toms. It may often happen that vomiting and diarrhoea have as an 
underlying basis this rhachitic disposition. 

With the above symptoms, and also in chronic cases, 'perspirations 
about the head are common. There is usually more heat of the head 
than is natural, hence in sleep the child rolls the head. This rolling 
causes the hair on the back of the head to be worn off. This sign is 
most characteristic of rhachitis when observed along with changes in 
the skeleton. 

In the acute and chronic forms enlargement of the liver and spleen are 
observed. The enlargement is not only actual, but also a false enlarge- 
ment may be seen from distortion of the organs on account of changes 
in the vertebrae and ribs. The abdomen is prominent, usually on ac- 
count of flatulency, although the enlarged organs contribute to the 
swelling. 

Of common symptoms in the course of rhachitis nervous phenomena 
are often observed. Tetany limited to the upper extremities, and laryn- 
gismus stridulus are the most frequent. Either of these complications 
may occur before the disease is otherwise suspected. 

Diagnosis. The possible presence of rhachitis must not be forgotten 
in chronic vomiting in childhood. The disease must not be confounded 
with scurvy, which in children is likely to be the case. This is especially 
so in the acute form. It must not be forgotten that the latter affection 
may set in in the course of rhachitis. In scurvy, the pain, tenderness, 
and weakness are limited to the lower extremities. The immobility of 
the extremities may go on to pseudo-paralysis. The tenderness, however, 



716 



SPECIAL DIAGNOSIS. 



is great ; oedema is more pronounced, and local areas of periostitis are 
more common. In scurvy the gums are swollen and may be spongy, 
or may be the seat of ecchymoses. The most decisive diagnostic criterion 
is the therapeutic test, scurvy rapidly yielding to a proper regimen. 

Scurvy. 

Scorbutus, or scurvy, is a constitutional condition brought about by 
a long-continued use of a diet deficient in fresh vegetables. It is char- 
acterized by pallor, great physical weakness and mental sluggishness, 
dyspnoea, subcutaneous and submucous hemorrhages, a swollen, spongy 
condition of the gums, and a brawny induration, especially of the calves 
and hams. 

The onset of the disease is gradual, and is marked by a peculiar dirty- 
yellow or greenish pallor of the face, associated soon with an apathetic 
expression of the face, physical weakness, and decided lack of customary 
energy. The appearance is so characteristic that patients are said readily 
to detect it in others, though unaware of it in themselves. Sleep and 
digestion are good, but rheumatoid pains may be complained of. Other 
prominent subjective symptoms are fatigue on slight exertion, dyspnoea, 
faintness, and despondency. In the course of a week or two petechia? 
appear upon the lower extremities, especially around a hair as the 
centre (see page 77). Depending upon the severity of the case there 
are also bullae, vibices, and ecchymoses. Brawny induration, due to 
deep effusion of blood, occurs especially in the calves and hams, pro- 
ducing considerable pain on flexure of the knees. 

There is no fever apart from complications. The pulse is frequent, 
weak, and small, and the first sound of the heart, and the impulse, may 
be very faint. 

The face is swollen and of a dirty, possibly greenish-yellow color, 
according to Bird, Buzzard, and others ; in some cases the eye and its 
surroundings are the only parts exhibiting signs of scurvy at this time. 
" The integument around one or both orbits is puffed up into a bruise- 
colored swelling. The conjunctivae covering the sclerotic is tumid and 
of a brilliant-red color throughout, and about the eighth of an inch in 
thickness or elevation above the cornea, leaving the cornea at the bottom 
of a circular trench or well." 1 The condition is not inflammatory. 
These cases often terminate fatally. 

Almost always the gums swell, become spongy, and bleed upon the 
slightest irritation. Sometimes they swell so as almost to hide the 
teeth completely, and even to protrude from the lips. The breath has 
a heavy, sickening odor, and the teeth sometimes drop out of their 
sockets. 

In addition to the cutaneous and gingival hemorrhages, hemorrhages 
occur from the nose and other mucous surfaces, and effusions take place 
into the lungs, intestines, pericardium, and pleura, associated with in- 
flammatory products. There may be no physical signs on the part of 
the lungs to account for the dyspnoea, or some dulness may be detected 
and bronchial breathing or a few rales. 



1 Buzzard : Reynolds' System of Medicine, 1880, vol. i. p. 451. 



CONSTITUTIONAL DISEASES. 



717 



A very peculiar symptom, and sometimes the earliest, is hemeral- 
opia, nyctalopia, or night-blindness, in which the patient can see 
during the day, but not by moonlight, and apart from artificial light is 
totally blind at night. 

The prognosis is much better when there are external phenomeua, 
even when they are very severe, than when these are absent. When 
there are marked pulmouary symptoms with tendency to syncope, the 
prognosis is grave. In general it is good if the disease can be brought 
under the influence of fresh vegetables and lemon-juice before it has 
seriously damaged the health. 

The course of the disease is slow. Death may take place suddenly, 
and sometimes early, from syncope, but usually it is due to exhaustion, 
or to some complication, as dysentery, pneumonia (with or without 
gangrene), or ulcerative endocarditis. 

Diabetes Mellitus. 

The occurrence of any of the following conditions should lead to an 
examination of the urine for sugar, and an estimation of the quantity 
of urine passed in twenty-four hours, apart from the routine examina- 
tion which should be made in every case of chronic disease or of 
obscure acute disease. 1. Muscular weakness without cause. The 
weakness is progressive and rapidly advances to an extreme degree. 
2. Emaciation. In young subjects this is rapid in cases of diabetes. 
In older patients it is not so striking, particularly if the gouty diathesis 
is present. 3. Thirst. This is a symptom which is of common occur- 
rence in diabetes, and is most distressing. If the amount of fluids 
taken be compared with the amount of urine excreted, it will be found 
that the two bear a definite ratio. The thirst is greater immediately 
after meals, although the patient does not necessarily have indigestion. 

4. Hunger. Excess of appetite, boulimia or polyphagia, also occurs in 
diabetes. The amount of food that is taken is sometimes enormous, 
and the ravenous manner in which it is partaken of is revolting. 

5. Loss of sexual power. 

The four symptoms just mentioned, with increased frequency in 
micturition, are the common symptoms of diabetes mellitus. They may 
develop gradually. In rare instances the onset is sudden. The occur- 
rence of these symptoms should lead at once to an examination of the 
renal secretion. 

Three special characteristics of the urine are observed. A. The 
amount is increased so that from six to ten pints to thirty or forty pints 
are passed in twenty-four hours. B. The specific gravity ranges from 
1025 to 1045, and may even be higher. C. The presence of sugar. 
The sugar is detected by the ordinary tests (see Examination of Urine). 
In addition the urine is usually of pale color, of a sweetish odor and 
acid reaction. 

In addition to thirst and increased appetite, some gastro-intestinal 
symptoms may be of diagnostic importance. Of these, first, the appear- 
ance of the tongue is characteristic. It is dry, red, and glazed. The 
dryness is aggravated by a scanty flow of saliva. The gums are swollen 



718 



SPECIAL DIAGNOSIS. 



and spongy, and stomatitis is often present. There are no marked 
dyspeptic symptoms. Constipation is of common occurrence. 

In diabetes other secretions are lessened in amount. Perspirations 
do not occur, except in inflammatory complications. The skin is harsh 
aud dry. As the disease progresses the heart's action becomes weak 
aud the pulse frequent and with lowered tension. The temperature of 
the body is usually below normal. 

Diabetes may occur at any age, but is most frequent in adult life. 
In young adults the symptoms are more pronounced, and the duration 
shorter. In patients past middle life the disease may continue for a 
long period of years without marked interference with the health and 
nutrition. 

While the symptoms just mentioned should lead to an examination 
of the urine, diabetes mellitus may not be suspected by any of the usual 
objective or subjective symptoms. It may happen that none of these 
symptoms are sufficiently marked, and that only by routine examina- 
tion of the urine, or by the occurrence of affections known to be 
associated with sugar in the urine, is the disease discovered. 

Of the complications which would lead to the suspicion of sugar in 
the urine the following are the most important : 

1. Cutaneous Complications. Boils and carbuncles should always lead 
to an examination of the urine. Pruritus and chronic eczema may have 
diabetes in the background. Gangrene of the extremities, chiefly of 
the feet and legs, and gangrene in other situations, is of common occur- 
rence in the course of diabetes. 

2. Lung Complications. Tuberculosis, both of the chronic and the 
acute pneumonic type, is frequently associated with diabetes. Lobar 
pneumonia is liable to occur. In all cases of pneumonia the urine 
should be examined for sugar. Its presence would modify the prognosis 
of an otherwise moderate case. Gangrene is liable to ensue in the 
acute and chronic lung affections. Gangrene of the lung in the course 
of diabetes may be latent and recognized only by the odor and the 
character of the expectoration, or it may run an acute febrile course. 

3. Nervous Symptoms. Diabetic coma is liable to develop in the 
course of the disease. In young subjects, particularly, the occurrence 
of coma should lead to a suspicion of diabetes. Such coma may occur 
before the disease has been recognized. The coma may follow an 
attack of fainting and prostration, with stupor, which deepens into com- 
plete unconsciousness. It may be preceded by nausea and vomiting 
or the lung complications previously mentioned. This form of coma 
is usually associated with extreme dyspnoea, and attended by agitation, 
pain in the head, and some delirium. The pulse becomes rapid and 
teeble, and coma develops gradually. For this form of coma the term 
acetoncemia is used. The breath is of peculiar sweetish odor, due to 
acetone, and this compound is detected in the urine. Coma may occur 
without any premonitory symptoms whatsoever, the patient reeling for 
a short time, and complaining of pain in the head as if intoxicated. 

Peripheral neuritis should always lead to an examination of the 
urine. It may be localized to one group of nerves, or may be more or 
less general with symptoms like those of locomotor ataxia, as the 



CONSTITUTIONAL DISEASES. 



719 



lightning pains, abolition of reflexes and loss of power in the extensor 
muscles. Diabetic patients are also subject to neuralgia, and to periph- 
eral hypersesthesia and paresthesia, probably due to neuritis. The 
neuritis may be so extreme as to lead to paraplegia. 

4. Eye Symptoms. A curious symptom of diabetes is the occurrence 
of cataract. This may develop at any age, and is often rapid in its 
course. Cataract or alterations of vision should always demand an 
examination of the urine. Diabetic retinitis is sometimes present. 
Atrophy of the optic nerves, or muscular insufficiencies, may take place, 
the latter causing the pronounced symptoms of eye-strain. Ringing 
in the ears, deafness, the occurrence of acute otitis, are phenomena which 
arise in the course of diabetes. 

Diagnosis. Sugar in the urine occurs temporarily when there is an 
excess of saccharine diet, or when there is functional disorder of the 
liver. The sugar is small in amount, and the glycosuria is transient. 
The diagnosis of true diabetes is not difficult, although it may be over- 
looked unless the habit, previously insisted upon, of constant urinary 
examinations is fully developed. 

Diabetes Insipidus. 

This form of diabetes differs from the preceding in that the large 
amount of urine is normal, but of low specific gravity. The disease 
may come on suddenly after mental emotion, or develop gradually. 
The amount of urine may range from ten to forty pints. The urine is 
of low specific gravity — from 1001 to 1005. It is pale and watery. 
The solid constituents are not reduced. Urea is sometimes increased, 
but abnormal constituents are very rare. The passage of large amounts 
of urine induces thirst, but otherwise the symptoms do not tally with the 
symptoms of diabetes mellitus. The patients are usually well nourished. 

The disease is usually secondary to some organic disease of the brain, 
or of the abdomen, as tuberculous peritonitis, abdominal tumors, or 
aneurisms. It usually occurs in males, and is often hereditary. It is 
most common in young people. Traumatism, meningitis, affections of 
the brain involving the sixth nerve, tumors of the brain or of the 
medulla, are causal factors. It may follow fright, a protracted spree, 
or perturbation of the nervous system from other causes. 

The diagnosis is not difficult. It must be distinguished from the 
polyuria that is seen in chronic interstitial nephritis, and in amyloid 
disease. In hysteria, polyuria is common, although it is transitory. 
The presence of the stigmata and other hysterical manifestations lead to 
the diagnosis. 

Haemophilia. 1 

Haemophilia is a constitutional affection characterized by bleeding, 
which is spontaneous or occurs upon slight injury. It is nearly always 
hereditary, but may arise de novo. 

Males are very much more liable to it than females, the ratio being 
about 11 to 1. This curious disposition to bleeding maybe transmitted 



1 See Hemorrhages, page 77. 



720 



SPECIAL DIAGNOSIS. 



for generations, and almost always to the males through the female mem- 
bers of the family — that is to say, the daughter of a bleeder is not 
usually affected, but she transmits the tendeucy to her sons, who become 
bleeders ; her daughters are not bleeders, but they in turn transmit the 
disposition to their male offspring. It generally shows itself early in 
life, usually before the end of the second year, aud almost invariably 
by puberty. 

The affection usually first declares itself by the occurrence of a hemor- 
rhage, either spontaneous or the result of slight injury, the bleeding 
beiug far more profuse than would be natural, and in some cases abso- 
lutely uncontrollable. 

Legg 1 has divided hsemophilia into three degrees, according to the 
severity of the symptoms. The first is characterized by exterual and 
internal bleedings of every kind, and by joint affections ; the second, by 
spontaneous hemorrhages from mucous membranes, but no traumatic 
bleeding or ecchymoses, and no joint affections ; the third, by a ten- 
dency simply to ecchymoses. The first form is seen most frequently 
in men ; the second most frequently in women ; and the third in either 
sex. 

The most frequent seat of hemorrhage is the nose, and the next the 
gastro-intestinal tract. The bleeding is from the capillaries ; it may 
prove fatal in a few hours, or last for days and weeks with final re- 
covery. Intense anaemia follows the prolonged hemorrhage, but the 
blood is replaced with remarkable rapidity. All operations, even the 
most trivial, are extremely dangerous in bleeders. Circumcision, ex- 
traction of teeth, and leeching are credited with the most deaths by 
Grandidier. 

Joint symptoms are very common. The knees, elbows, ankles, and 
shoulders are the ones most frequently involved. The attack may be 
marked by pain, redness, swelling, inflammation, and fever ; or fever 
may be absent ; or pain alone be complained of. The attacks are liable 
to recur, especially in cold, damp weather, and may result in stiffened, 
deformed joints. 

The diagnosis (see page 77) is easy when the history of an hereditary 
tendency to bleed can be obtained. Osier properly remarks that slight 
joint trouble and petechia? are as much a manifestation of the disease as 
the more severe hemorrhages. In cases in which no such history can be 
got the diagnosis is made by noting a persistent liability to hemorrhage, 
without adequate cause, and associated with joint affections. 

Osier gives the following excellent summary of the affections with 
which haemophilia can be confounded : 

1. The umbilical hemorrhages of infants, due to jaundice or to syph- 
ilis hemorrhagica neonatorum, etc. 

2. Purpura simplex, often seen in debilitated, rarely in healthy chil- 
dren, usually confined to the legs, and in some cases associated with 
rheumatic pains or swellings in the knees and ankles. 

3. Peliosis rheumatica. 

4. Purpura hemorrhagica, morbus maculosus Werlhofii, a grave dis- 

1 Haemophilia. London, 1892. 

2 Quoted by Osier, Pepper's System of Medicine, 1885, iii.932. 



CONSTITUTIONAL DISEASES. 



721 



ease, characterized by extensive cutaneous ecchymoses, mucous hemor- 
rhages, but not dependent on any local disease or, as far as is known, on 
any specific poison. 

5. Infective purpura due to the action of some specific poison — small- 
pox, measles, scarlet fever, cerebro-spinal fever, etc. The hemorrhages 
may be cutaneous and trivial, or may be in the most aggravated form of 
interstitial and mucous bleedings, as seen, for example, in black smallpox. 

6. Toxic purpura, as in snake-bites and many poisons, such as phos- 
phorus. 

7. Simple hemorrhagic diathesis, under which may be included those 
cases in which, without any hereditary disposition or previous hemor- 
rhagic history, there is a tendency to uncontrollable hemorrhage from 
a slight wound. 

8. Haematic! ros is, bloody sweats, which occur usually in hysterical or 
epileptic females, and are in rare instances accompanied with mucous 
hemorrhages. 

Purpura. 

Secondary purpura occurs in connection with a variety of febrile and 
constitutional diseases: 1. Scurvy. 2. Haemophilia. 3. Hodgkin's 
disease. 4. Splenic leucocythsemia. 5. Pernicious ansemia. 6. 
Chronic lesions of the kidney and liver. 7. Ulcerative endocarditis. 
8. Malignant sarcomata. 

Primary purpura occurs without any known cause. It has been 
divided for convenieuce into simple and hemorrhagic purpura, though 
the two probably differ only in intensity. 

1. In simple purpura the hemorrhages are limited to the skin (see page 
77). They consist of: 1. Bright-red spots, varying in size from a pin- 
head to a silver three-cent-piece. These spots are under the skin and are 
unaffected by pressure. They fade gradually from red to yellow and 
disappear. 2. Larger spots or streaks called vibices. 3. Ecchymoses. 

The disease is said to be most common about the age of puberty. It 
may come on in the midst of apparent health, or it may follow an 
illness, as of typhoid fever. 

Purpura occurs especially upon the legs, the standing position seem- 
ing to favor its occurrence. It comes out in successive crops. Some- 
times large blebs filled with thin blood form under the skin, and 
gangrene at times occurs. 

2. In the hemorrhagic form, 1 hemorrhages occur from the nose, stom- 
ach, bowels, vagina, and bronchi, or into the kidney or other viscus. 
Cutaneous and submucous hemorrhages also occur. 

The onset of these cases is sudden, though there may be a day or two 
of depression, lassitude, headache, and nausea. The first symptom 
noticed is generally fever, which is apt to be moderate, then the erup- 
tion upon the skin is detected, and for a day or two the patient may 
seem to be only slightly ailing. Copious epistaxis may now occur, or 
a hsematemesis or hematuria, or all of these and other hemorrhages 
may occur the same day. The temperature may be only moderately 



1 See " Grave Forms of Purpura Hemorrhagica." Musser, Trans. Association of American Physi- 
cians, vol. vi. 

46 



722 



SPECIAL DIAGNOSIS. 



raised, or it may reach 104° to 105° or even higher. The pulse at first 
is frequent (120 to 140), but of good volume and tension. Subsequently 
in unfavorable cases it becomes thready and very frequent. Respiration 
is not affected, and the mind is clear ; the face is pale and anxious. 
Hemorrhage may also occur into the choroid aud brain substance, with 
blindness and paralysis as sequels. It may also occur into the uvula or 
tonsil. 

The subjective symptoms are pains in the loins, limbs, epigastrium, or 
chest. Often these pains announce a fresh hemorrhage, as into the 
kidney, or a fresh crop of purpuric spots. The degree of anaemia 
present depends upon the copiousness of the hemorrhage and the length 
of time the disease lasts. Sometimes the hemorrhages cause great 
exhaustion, with a tendency to collapse. 

The urine, in the case of hemorrhage into the kidney, of course con- 
tains blood ; sometimes casts are also found. 

3. Another variety of purpura is known as peliosis rheumatica, the 
peculiar features of which are tender and swollen joints, oedema of the 
subcutaneous cellular tissue, and purpura associated with urticarial 
wheals and intense itching (purpura urticans). The subcutaneous hem- 
orrhages consist of petechia?, vibices, and ecchymoses. There may be 
such large hemorrhages into the penis, scrotum, and uvula as to result 
in gangrene and slow separation of the dead tissue by ulceration. 
Epistaxis may occur, but copious hemorrhages from the stornach, the 
bowel, or into the kidney or other organs are rare. Endocarditis and 
pericarditis occur as complications in some cases. The duration is apt 
to be tedious, convalescence being delayed by repeated outbreaks of 
purpura with multiple arthritic symptoms and oedema. 

Diagnosis. It is distinguished from scurvy by the absence of ante- 
cedent debility and anaemia, of spongy gums, of brawny induration in 
the limbs, and by the fact that there is no tendency for the hemor- 
rhages to occur around a hair follicle. In scurvy there is a history of 
deprivation of vegetable food, whereas purpura may occur in the midst 
of robust health. As a rule the cutaneous hemorrhages are larger in 
scurvy than in purpura. 

It is distinguished from acute infectious diseases, particularly typhus, 
cerebro-spinal fever, and smallpox, by the absence of the severe consti- 
tutional symptoms which characterize the graver forms of these dis- 
eases — in which alone a purpuric eruption is likely to be severe enough 
to cause doubt. Hemorrhages from mucous surfaces are rare in the latter. 

Hcemophilia is distinguished by the history the patient gives of being 
a bleeder by heredity, and the fact that the bleeding has been started 
by some injury, wound, or operation. 

It is distinguished from the hemorrhages of leukcemia by the absence 
of enlarged spleen and liver, and by the fact that there is no excess of 
leucocytes in the blood. 

Malignant sarcoma causing hemorrhages is recognized by the pre- 
vious history of anaemia and cachexia, and by the detection of primary 
or secondary growths. 

It must not be confouuded with Raynaud's disease, sl vasomotor affec- 
tion characterized by local syncope, local asphyxia, and gangrene. 



CHAPTEE X. 

THE INFECTIOUS DISEASES. 

The specific infectious diseases are those that are produced by a living 
contagion or micro-organism. The organism is introduced into the body 
through the skin, if the latter is the seat of some lesion, as in syphilis, 
tuberculosis, and anthrax ; through the air-passages, as in diphtheria, 
scarlet fever, and other specific fevers ; or through the digestive tract, 
as in typhoid fever, dysentery, and cholera. 

The virus, as the living cause is named, in many instances produces 
certain changes at the point of entrance — the initial phenomena. It is 
then conveyed by the lymphatics or bloodvessels to near-by organs in the 
related lymph or blood stream, or transmitted to the whole body. When 
the whole body is affected sometimes an eruption is produced (eruptive 
fever), or the blood is changed in quality (diphtheria), or many tissues 
are affected simultaneously, or the nervous system notably disturbed. 
The above are the phenomena of general distribution of the virus, or of 
infectiveness. The virus or poison thus distributed may be the living 
organism, as in tuberculosis or anthrax, or it may be a poison generated 
by the organism, a toxin or ptomaine, as in diphtheria. 

Phenomena of secondary local distribution are due to local changes in 
organs affected secondarily. The poison has a special affinity for cer- 
tain organs, as in whooping-cough, parotitis, pneumonia, or leprosy. 

In some instances the local phenomena are so marked as to give to 
the disease a corresponding distinctive feature. They are the granu- 
lomata. 

Bearing in mind the above distinctions, specific infectious diseases are 
divided into six classes. 

Fikst Class. Acute Specific Fevers. The initial phenomena are 
slight. The phenomena of infectiveness are marked ; an eruption is 
one of the most characteristic. The secondary local phenomena are 
variable. The following are included in this class : Typhoid fever, 
typhus fever, variola, varicella, scarlet fever, measles, relapsing fever, 
plague, and cholera. 

Second Class. Specific Inflammation. Initial phenomena indefinite. 
General phenomena (infectiveness) variable, but no eruption. Specific 
affinity of poison for one particular structure. Whooping-cough, 
mumps, diphtheria, dysentery, erysipelas, tetanus, hydrophobia, pneu- 
monia belong to this class. 

Third Class. Contagious Suppurations. Initial phenomena marked 
(suppuration) ; generalization not marked unless the virus enters the 
blood ; secondary local phenomena decisive. Gonorrhoea is one type, 
pyaemia a second, in which the blood is infected. 

Fourth Class. Infective Granulomata. Distinct initial phenomena. 



724 



SPECIAL DIAGNOSIS. 



Phenomena of generalization not marked, or like specific fevers. Sec- 
ondary local phenomena prominent. Examples : Tuberculosis, syphilis, 
leprosy, and glanders. 

Fifth Class. Miasmatic Diseases. No initial phenomena. 

Sixth Class. Vegetable Parasitic Diseases. 

The infectious diseases, as pneumonia and dysentery, not included 
in this section, are considered under local diseases as a matter of con- 
venience. 

Typhoid Fever. 

An acnte, specific, infectious and mildly contagions fever, characterized 
by a gradual onset, a continued fever, an eruption of rose-colored spots, 
marked nervous and abdominal symptoms, and an average duration of 
three or four weeks. 

It occurs sporadically and epidemically, and in large cities is apt to 
be endemic. Its special habitat is in temperate climates, but it may 
occur anywhere. It is relatively rare in the southern and southwestern 
portions of the United States. It is more frequent in the latter part 
of the summer and in the autumn and winter, and following hot and 
dry summers. Young adults are especially prone to it, but cases have 
occurred at all ages. Change of residence from the country to the 
city predisposes to it. Those living in cities often acquire immunity, 
but they may lose it npon moving elsewhere. The state of previous 
health does not seem to have any influence. 

In by far the larger number of epidemics the poison has been con- 
veyed in the water, in a few instances in the milk previously contami- 
nated by water. In sporadic and endemic cases the poison may be 
obtained from defective house drainage and from damp, unwholesome 
cellars. The specific cause of the disease is believed to be a bacillus 
described by Eberth and others. 

The period of incubation in typhoid fever varies from four or five 
days to three weeks ; more commonly it is from one to two weeks. 
During this time the patient usually is languid, becomes tired easily 
upon exertion, has severe headache, and sleeps poorly. There is often, 
even thus early, a dull and listless expression of the face. Toward the 
close of this period, and in severe cases, there may be colicky pain in 
the abdomen, a tendency to looseness of the bowels, cough, epistaxis, 
mental sluggishness, and chilliness. Dr. Pepper says he has been led 
repeatedly to anticipate the approach of typhoid fever by the unusual 
dulness of hearing and by the persistent occipital headache coming on 
after a few days of general malaise. 

While the disease may begin abruptly, a gradual onset is so much the 
rule that it becomes important in the diagnosis from other disease con- 
ditions. 

Invasion is not sharply marked. There may be chilliness, but a 
decided chill is unusual except when pneumonia is part of the initial 
process. Muscular weakness, headache, and mental sluggishness are 
more pronounced, and the physician is consulted because these symp- 
toms persist, or because fever is discovered. The beginning of fever 
is the most constant indication of the onset of the disease, and two 



THE INFECTIOUS DISEASES. 



725 



very important early symptoms are cough and enlargement of the 
spleen. 

The most prominent and constant subjective symptom during the 
first week is headache. Other very common symptoms are tenderness, 
rarely pain, in the iliac region, more or less prostration, and impaired 
or lost appetite. 

The objective symptoms are therefore the most important. The face 
is pale rather than flushed, and has a dull, listless, apathetic expression 
upon it. The tongue is heavily coated with a white fur which becomes 
yellow. The abdomen is somewhat distended and tympanitic on per- 
cussion. There is usually tenderness in the right iliac region, and 
gurgling upon palpation is pretty constant. Constipation may be present 
at first, and sometimes persists throughout the disease. A tendency to 
diarrhoea is, however, characteristic of the disease. Even if constipa- 
tion exist at first, a laxative is apt to produce an excessive effect. The 
number of passages varies from two or three to a dozen or more in 
twenty- four hours. They are light yellow in color (" pea-soup"), thin, 
watery, and offensive. The movements are not usually accompanied 
with pain, but in severe cases may occur involuntarily. 

Enlargement of the spleen is a very constant symptom. It may be 
detected at the onset, increases up to the height of the fever, subsides 
during convalescence, but recurs during a relapse. It covers a percus- 
sion area in the left hypochondrium of four to eight finger-breadths. 



Fig. 133. 







E 


M 


E 




c 


M 


E 


M 


E 




E 








E 




E 


M E 


M 


E 






M 


E 




E 




E 






























































































































104- 
















































































r 




i 


























ft 














103- 




























1 
































































V 






H 






















































































102— 








/ 




























































f 
























































101— 


























































































































































































Hay ofJMs. 




} 




! 




I 






0 












1 


0 


11 


1 




1 


:? 


14 






1 






80 










83 










^^82 











Mild typhoid fever. Gradual ascent. 



The temperature curve when not modified by treatment shows a 
gradual ascent during the first four or five days of the disease, with a 
morning remission. The temperature rises a degree or two in the 
evening and falls half a degree or a degree in the morning. This 
"step-ladder" ascent is very characteristic. By the end of the week a 
temperature of 103°, 104°, or 105° has been reached, and it remains 
continuously high, with slight morning remissions, during the second, 
and less frequently during the third week. In the third or fourth week 
the morning fall of temperature gradually becomes greater, and by the 
end of the week sinks below normal in the morninp;. 



THE INFECTIOUS DISEASES. 



727 



The temperature in mild cases may never rise above 103° at any time, 
and most of the time varies between 100° and 102°. Or it may be 
104° from the start; more frequently during the second and third week 
there are marked oscillations of the temperature — a sudden fall from 
104° to 101°, or a rise from 103° to 105° or 106°. Hyperpyrexia is 
a temperature above 105°. 

The pulse is full, and in favorable cases slower than the pyrexia 
would lead one to suppose. It is more frequently under 110 than over 
120. In the second week it is markedly dicrotic. 

The heart sounds are unchanged apart from complications, but in the 
second and third weeks the first sounds often are feeble, indicating heart 
weakness. A pulse of 120 or more is a graver sign in typhoid fever 
than in other diseases. Therefore when it becomes very frequent and 
feeble, the extremities cool and the lips bluish, the outlook is gloomy. 

The urine is at first scanty and high-colored. A slight degree of 
febrile albuminuria is not uncommon, and in rare cases the whole force 
of the poison seems to be spent upon the kidneys, the urine containing, 
besides the usual blood and casts, biliary coloring matter. In con- 
ditions bordering on coma the patient may have retention of urine, or, 
on the other hand, he may pass it involuntarily. The diazo reaction 
of Ehrlich is obtained by mixing forty parts of a one-half per cent, 
solution of sodium nitrite with one part of a one-half per cent, solution of 
hydrochloric acid saturated with sulphanilic acid. Equal volumes of 
the mixture and of urine are shaken up in a test-tube and covered with 
ammonia. At the junction of the two a pink or ruby ring develops. 
This reaction is helpful in diagnosis, but may occur in acute phthisis, 
tubercular meningitis, and other diseases. According to Pepper it is 
rarely absent in measles. 

The respiration in uncomplicated cases increases in frequency with 
the rise in temperature. It usually ranges between 24 and 36. The 
slight bronchitis present in the beginning in most cases causes no 
trouble ; sometimes it lasts throughout and contributes to the tendency 
to hypostatic congestion always present. The physical signs are those 
described elsewhere in these conditions. 

The nervous symptoms are often very prominent. In mild cases they 
consist of hebetude and nocturnal delirium, or they may be absent 
altogether. Usually, however, by the beginning of the second week 
there is some mental confusion with nocturnal delirium. In more 
severe cases and later in the disease the delirium is of a low, mut- 
tering character, with hallucinations of sight and sound more or less 
continuous. The patient can be roused by a question, and makes an 
intelligent answer, but speedily lapses into semi-consciousness. Pick- 
ing at the bedclothes or efforts to catch imaginary objects are very 
common. Sometimes the delirium is wild and noisy, and the constant 
presence of some one is needed to keep the patient from getting out of 
bed. Patients have jumped out of windows, or run long distances 
before being captured. Rarely the delirium has been so active as to 
simulate acute mania. Stupor may alternate with delirium. Rarely 
the patient lies with wide-open eyes, apparently staring fixedly at some 
object, but really unconscious (coma vigil). 



728 



SPECIAL DIAGNOSIS. 



In ataxic cases the patient has marked twitching of the tendons and 
jactitation. He is wakeful and restless, wearing himself ont. The 



Fig. 135. 



106- 


H 


L 




. 


M 


E 


M 




M 


E 


M 




M 




M 




M 




M 


e 






M 


E 


M 


E 


M 




1 E 






























































105- 




















A- 








































104- 




















'4 




































































\ 








A 
























103 












J 




























1 










f 






















































































































f 












102- 


































































A 


\ 












































i 






101- 




















































































































3Jay ofDK 


r 


l 














< 




























1 








Date 
























CO 
11 









Grave typhoid fever. Death. M., set. 22. Ataxic symptoms. 

hands and lips tremble, and he keeps muttering to himself all the 
time. 

Fig. 136. 







E 










M 


E 




E 








E M 


E M E 




E 




E 




E 




E 


105- 
















































































































































104— 








A 
















f 






























? 










































103- 




J- 
























T 


















































































































102 — 






























































I" 


































ioi c - 




















































































A 




























































100 - 


















































































1 














99 - 
































































































98 
















































































































































97- 














































































:=3 


















06- 

















































Typhoid fever in a child set. 12. Chart from twelfth to twenty-third day. (Frequent 
mode of termination in children.) 



Convulsions are rare, but may occur in children. Sometimes there 
is considerable hyperesthesia and tenderness along the spine. 



THE INFECTIOUS DISEASES. 



729 



The extent of the nervous symptoms depends upon the habit of the 
patient as well as upon the height of the temperature and gravity of 
the disease. They may be pronounced in children and neurotic indi- 
viduals with moderate fever. 

On the seventh or eighth day the eruption appears. It consists of 
small, very slightly elevated, rose-colored papules, which disappear 
upon pressure and come out in successive crops, each papule lasting 
three or four days. The spots are most common over the abdomen and 
back, but are occasionally found elsewhere. They are usually few in 
number, a half-dozen or dozen, but sometimes the eruption is very 
copious. This is more apt to be in severe cases. Sometimes it is 
wholly absent. 

Fig. 137. 





M E 




E 








t 




E 




E 




E 






M e 




E 


E 


















































































103. 
































































































\ 






















102- 




f 
























































y 




















101- 




























k 


s 




















* 






































































100- 
















































































99" 


















































































+■ 






































92- 
















































































0- 
97" 
























































































































Puise 




= V 




: 






V s 
























Date 










X 




~\ 






a 





Course ol temperature in a relapse beginning on twenty-sixth day. First attack mild. 

During the latter part of the second week and through the third 
week the symptoms are apt to be intensified. The temperature keeps up 
or even reaches a higher figure. Delirium is more decided and constant. 
The heart grows weak and the pulse increases in frequency. Some 
degree of hypostatic congestion of the lungs is usual. Diarrhoea may 
be troublesome ; intestinal hemorrhages, announced by sudden fall of 
temperature and symptoms of collapse, may occur. Tympanites may 
become so great as to interfere with respiration and circulation. This 
is the period when ulceration of Peyer's patches in the intestine is 
deepest, and perforation is imminent. There is rarely any desire for 
food, though it is taken and assimilated. Nausea and vomiting are rare. 
But the tongue is dry, brown, sometimes glazed and fissured, and sordes 
often collect on the teeth. 

In cases ending in recovery the temperature begins to fall in the 
mornings ; delirium grows less ; sleep is more refreshing. Diarrhoea 



730 



SPECIAL DIAGNOSIS. 



ceases, and constipation may even require treatment. The pulse does 
not usually improve as rapidly as the other symptoms. There is some- 
times very marked anasmia without leucocytosis (Osier). When the 
temperature sinks to normal or subnormal, convalescence has set in. 
This is very rapid as far as digestive symptoms are concerned, but the 
strength returns very slowly. It may be interrupted by a relapse, in 
which the original symptoms are reproduced, with high temperature 
but of shorter duratiou. 

Varieties. The abortive form is so named because of the abbre- 
viated course of the disease. The symptoms are sufficiently well 
marked to make the diagnosis clear, but the type is mild, and in a week 
or two convalescence is established. 

Fig. 138. 



97 



_2£ 



Grave typhoid fever. Daily rigors. Death on nineteenth day. No complications. 



In the ambulatory form, commonly called " walking typhoid," the 
patient, from ignorance of the gravity of his ailment or from apparent 
necessity, keeps at his work until weakness aud incessant headache lead 
him to consult a physician in his office or at a dispensary. He may 
then be well into the second week of the disease. The majority of 
such cases prove fatal. 

In the pulmonary form the onset may be so obscured by severe 
bronchitis or lobar pneumonia that the primary disease is not suspected 



THE INFECTIOUS DISEASES. 



731 



at first. Severe bronchitis seems to be more common in children. 
Chill and initial high temperature are common in these cases. 

Grave forms are due to especial severity of some symptom or group 
of symptoms, such as hyperpyrexia ; profound stupor, coma, or intense 
ataxia ; inability to take or retain sufficient nourishment ; profuse 
diarrhoea and iutestinal hemorrhage ; great adynamia with weak heart 
and a tendency to cyanosis. In other cases the gravity results from 
the existence of complications. 

In the malignant form there has been a large dose of the poison or a 
very weak organism, or both, the result being an acute toxaemia; this is 
not so common as in scarlatina and typhus fever. Other relatively rare 



Fig. 139. 





E 




E 




E 






















\ 






















































107- 
















































































































106- 


















































































































































105- 


























































1 






















































104— 












































































103- 










— A— 




































-v- 




1 




























































102- 










































4 




1 




t 




























-I- 


































IOI — 




















! 1 




































\ 






















































100- 
























































































































































99- 














































1 
































































3):i1e 

































Renal typhoid. Nephritis on the twenty-fifth day. Course of temperature during 
three days preceding death. 

forms are the renal and afebrile. Typhoid fever may be accompanied 
by a number of complications, the most frequent and important being 
severe bronchitis, hypostatic congestion with oedema, and true lobar 
pneumonia; bedsores; parotitis; phlebitis, especially of the femoral 
vein ; peritonitis from perforation of the bowel ; meningitis, acute mania, 
or mental decay ; jaundice ; myocarditis ; periostitis and osteitis. 
Sequelae are not frequent. Sometimes, however, the foundation is laid 
for permanent ill health. There may be impairment of the senses, 
mental weakness, and even insanity. Paralyses, neuritis, hyperesthesias, 
chorea, and epilepsy are occasional sequels. 

Bacteriological Diagnosis. Eberth's Bacillus. The bacillus is 
found in colonies in the spleen, liver, mesenteric glands, kidneys, and 



732 



SPECIAL DIAGNOSIS. 



intestines of cases of typhoid fever. It is also found in the faeces and 
rarely in the urine. It may be seen in the blood. 

Morphology. A bacillus 1 to 3^ long by 0.5 to 0.8 y- broad, with 
rounded ends. It is motile, facultative anaerobic, does not liquefy 
gelatin. It has flagella 3 to 5 times as long as the bacilli. It stains 
with the anilines, best with Lofner's blue. The flagella are stained by 
Loffler's special method. (See Plate L, Fig. 6, B.) 

Biological Properties. It grows readily in acid media as well as in 
the neutral or alkaline media, best at a temperature of 38° C. (Death- 
point, 60° C.) 

The organ from which a culture is to be made is washed carefully in 
a bichloride of mercury solution. Then three cuts are made with 
different sterilized knives, the third cut reaching the central part of the 
organ. A little of the tissue is then taken with a platinum needle and 
inserted into the tubes. 

The colonies develop in twenty-four to forty-eight hours. On 
gelatin plates they are small and white, nearly spherical ; irregular, 
granular, and yellowish brown. 

In stab cultures there is a whitish semi-transparent layer on the 
surface with sharply defined irregular edges, and along the puncture 
a grayish-white growth. (See Plate II., Fig. 5.) 

It develops abundantly in milk. On potato it forms an " invisible 
growth" manifested only by increase in moisture, which is quite 
characteristic. 

Diagnosis. A typical case of typhoid fever should not be mistaken 
for any other affection, but atypical cases are numerous. The most 
common sources of error are a hurried diagnosis and a willingness to 
accept a demonstrable local affection as sufficient to account for the condi- 
tion. In this way the significance of bronchitis, pneumonia, and diarrhoea 
is overlooked. In the symptomatic form there will almost always 
be found a history of gradual onset and a degree of fever and prostra- 
tion greater than should attend the purely local affection. Moreover, 
in bronchitis and pneumonia which are a part of typhoid fever there 
may be found tenderness with gurgling in the right iliac region, en- 
largement of the spleen, and epistaxis, to aid in the diagnosis ; while 
in cases in which the diarrhoea leads to uncertainty, bronchitis, enlarge- 
ment of the spleen, and epistaxis may coexist. 

New Diagnostic Sign of Typhoid Fever. Dr. Simon Baruch writes 
as follows : "As soon as a patient shows a rectal temperature above 
102.5° in the morning and 103° in the evening for three successive 
days, especially if this be accompanied by headache, dulness, or apathy, 
he is placed in a full bath at 90°, which is reduced to 80°, with con- 
stant friction over the body. In three hours, the temperature still 
being above 102.5°, he receives another bath 5° cooler. This is repeated 
until the temperature of the bath is 75°. If one or more of these baths 
fails to reduce the rectal temperature 2° in half an hour, the diagnosis 
of typhoid fever is almost certain, and the bath treatment is continued. 
The resistance of the rectal temperature to a bath of 75° for fifteen 
minutes, with friction, 'is an almost certain test of typhoid fever." 1 Dr. 



1 New York Medical Journal, September 2, 1893. 



THE INFECTIOUS DISEASES. 



733 



Baruch cousiders that the diagnosis of this disease should no longer be 
obscure, even in the first days of its course. 

Appendicitis is more likely to be mistaken for typhoid fever than the 
contrary. There is usually a history of constipation, though the occur- 
rence of several inadequate movements a day may conceal the fact that 
there is a faecal accumulation. The onset is more abrupt and the local 
symptoms more pronounced than in typhoid. Pain and tenderness are 
prominent, and while they may be general over the abdomen at first, 
they are found to be more acute in the iliac region and loin. Here, in 
place of gurgling, we find some increase of resistance on palpation, and 
a relatively dull note — a wooden sort of tympany — or there may be a 
demonstrable tumor. The patient lies with the right leg drawn up, 
has moderate fever, and vomiting. In fact, the attack is often intro- 
duced by chilliness and vomiting. Headache is not a prominent symp- 
tom, while bronchitis and enlargement of the spleen are absent. 

Acute right-sided salpingitis simulates typhoid fever. It is distin- 
guished by the history of a preceding vaginitis, endometritis, or abor- 
tion, by the absence of diarrhoea, enlargement of the spleen, and the 
characteristic eruption. A digital examination through the vagina 
discovers the womb pressed to one side and fixed, and a tender mass 
blocking up the pelvis. 

Simple continued fever is distinguished from typhoid fever of a mild 
type principally by the absence of bronchitis, enlargement of the spleen, 
epistaxis, and characteristic eruption. Constipation is more common 
than looseness of the bowels, and gurgling is absent. 

Typhus fever is distinguished by its sudden onset, the besotted ex- 
pression of the face, with reddened eyelids and small pupils, the absence 
of abdominal symptoms, and the occurrence on the fourth day of 
maculae, which are subsequently converted into petechiae. It is of 
shorter duration, and terminates very abruptly by crisis. 

Relapsing fever differs from typhoid fever in its sudden onset with 
chill, pain in the epigastrium, but absence of abdominal symptoms and 
eruption ; in the absence of marked nervous symptoms, in spite of the high 
fever ; the short duration and termination by crisis, and characteristic 
relapse at the end of a week. The conclusive test is finding spirilla in 
the blood. 

Acute tuberculosis of the lungs, at times, closely resembles typhoid 
fever. In both the onset is gradual, with cough and fever. In the 
former, however, the bronchial symptoms are more prominent, there 
are apt to be recurring chills and sweats, the temperature is remittent 
and irregular, emaciation is rapid, and constipation instead of diarrhoea 
is the rule. 

In peritoneal tuberculosis there is persistent pain in the abdomen, 
which is general ; the belly is swollen. If effusion occurs, the per- 
cussion note is dull. The temperature is irregular and may be below 
normal ; nervous symptoms comparable to those of typhoid are wanting. 

Meningitis before the stage of effusion exhibits exaggeration of the 
reflexes and marked hyperesthesia. There may also be muscular 
rigidity. The patient is restless, easily annoyed, and "fussy" about 
things that would be unnoticed by a typhoid patient. Vomiting is 



734 



SPECIAL DIAGNOSIS. 



often present, whereas it is rare in typhoid fever. The temperature 
does not maintain so high an average rauge as in typhoid and is sub- 
ject to greater oscillations. The pulse varies greatly, and may be 
irregular. 

In septic meningitis the headache and vomiting are more persistent, 
the bowels are confined, and the abdominal walls are retracted. There 
may be double optic neuritis. In tubercular meningitis the knee-jerk 
and other reflexes are variable, irregularly absent or present. In typhoid 
fever they are always present. In the former, choroidal tubercles may 
be seen with the ophthalmoscope. In tuberculosis in all forms leuco- 
cytosis is present ; in typhoid it is absent. Typhoid fever must not be 
confounded with tricliiniasis ; the peculiar muscular pain and oedema 
do not occur in the former. Uraemia may simulate typhoid fever when 
it becomes chronic, but the age, the characters of the urine, the cardio- 
vascular symptoms, are diagnostic, and with the absence of the specific 
typhoid symptoms render the diagnosis easy. 

Typhus Fever. 

An acute contagious and infectious fever, occasionally occurring 
sporadically and liable to be epidemic in the presence of destitution, 
filth, overcrowding, and bad ventilation. It is characterized by abrupt 
onset with chill or chilliness, a rapid rise of temperature, lassitude, 
headache, and pains in the back and limbs. On the fifth day a peculiar 
spotted eruption appears, which at first is macular and subsequently 
petechial. It is further characterized by adynamia Or ataxia, low mut- 
tering delirium, a suffused, heavy, drunken expression of countenance, 
by the absence of local disease, and by a crisis which occurs on or about 
the fourteenth day. 

Typhus fever is variously known as ship-fever, jail-fever, camp-fever, 
etc., names which sufficiently indicate its tendency to develop in the 
presence of filth, overcrowding, and privation. It is rare in this 
country, but is occasionally introduced at our seaports. 

The period of incubation is usually about twelve days; it may be 
five or eight days, or even a shorter time, depending upon the virulence 
of the poison and the susceptibility of the patient. Malaise may pre- 
cede by a day or two the onset of the disease. 

Invasion is characterized by headache, faintness, vertigo, chilliness, 
or a distinct rigor, pains in the back and thighs, loss of appetite, nausea, 
constipation, and extreme weakness. The prostration is sometimes so 
great as to compel the patient at once to go to bed. The temperature 
rises rapidly to 104° or 105° at the end of the second or third day. 
The pulse is frequent, 100 or 140, and in grave cases shows a marked 
tendency to become small, soft, and feeble. The patient is restless and 
sleepless, and is annoyed by tinnitus. The expression of the flushed face 
is listless and dull. 

About the fourth or fifth day the typhus eruption begins to appear. 
It consists at first of dull-red spots of irregular size and shape. They 
are most numerous on the covered parts. Moore 1 says they are 

1 "Eruptive and Continued Fevers," by J. W. Moore, Dublin, 1S92. 



THE INFECTIOUS DISEASES. 



735 



detected first near the axillae and on the wrists, then on the sides of the 
abdomen, afterward on the chest, back, shoulders, thighs, and arms. 
The skin is mottled by another crop of maculae under the skin ("mul- 
berry rash "). 

When the disease is fully developed the face is flushed, the conjunc- 
tivae red, the pupils coutracted so as to resemble pin-holes ("ferrety 
eye"), the tongue dry and brown, the teeth covered with sordes, the skin 
dry, hot, and stinging to the touch. The patient lies upon his back 
oblivious to all his surroundings. Headache has given place to delirium, 
which may be wild and fierce, but is more commonly low and mutter- 
ing. There are marked ataxic symptoms — subsultus tendinum, tremors, 
picking at the bedclothes. Incontinence of urine and faeces sometimes 
occurs. The breathing is frequent, shallow, and noisy, and the pulse 
frequent, soft, and feeble. The macular rash now becomes petechial. 
The patient is in a typical " typhoid state." The stupor may gradually 
clear up, or, on the other hand, deepen into coma ; or the patient may 
die from progressive weakening of the heart, with or without pulmonary 
complications. 

In the majority of the cases which end in recovery, on or about the 
fourteenth day the first sign of recovery is a sound sleep, from which 
the patient awakes refreshed and rational. The temperature falls with 
great rapidity, the pulse and temperature improve ; a typical crisis has 
occurred. 

Certain objective phenomena of the disease require special mention. 
The eruption is more copious in severe than in mild cases. A dull 
and livid color is a grave sign. Purpura and hemorrhages are some- 
times met with in bad cases. The eruption does not occur in successive 
crops. 

The patient seems to be surrounded by a vapor of a pungent, musty 
odor which is peculiar. 

The heart early shows the effect of the poison. The impulse is 
diminished, and the first sound less distinct. In grave cases with 
threatening heart-failure the sounds are feeble and distant, the impulse 
imperceptible. 

The pulse is usually increased considerably in frequency, but may 
be abnormally slow (50 and even 30 per minute), which is sometimes 
a bad sign. 

The weak heart and prostrate position of the patient favor congestion 
with oedema of the lungs. This condition is common. 

Digestive symptoms have been referred to already. Vomiting, 
tympanites, and diarrhoea are rare, and still more so is intestinal hemor- 
rhage. 

The urine is scanty and high-colored. Slight albuminuria is com- 
mon, and a few casts are found ; but distinct nephritis is unusual. 
Convulsions, when they occur after the first week, are almost always 
uraemic and are almost invariably fatal. Some curious instances 
have been recorded by Stokes and Corrigan in which the convulsions 
were due to retention of urine. 

The duration of the disease is from six to fifteen days ; the average 
period is twelve or fourteen days. An abortive form is met with in 



736 



SPECIAL DIAGNOSIS. 



some epidemics, the disease being of a mild type and subsiding at the 
end of a week. It is also possible for so large a dose of the poison to 
be received that the patient is stricken down in a few hours or a few 
days. To this form the name " blasting typhus" has been appropri- 
ately given. 

The most important complications are hyperpyrexia, laryngitis, 
bronchitis and congestion of the lungs, extreme ataxia or profound 
adynamia, nephritis, heart failure, and parotitis, or other inflammatory 
glandular swellings. 

Laryngitis with oedema is a rare but very dangerous complication. 

Diagnosis. Cerebrospinal fever is distinguished from typhus fever 
by greater intensity of the headache, by retraction of the head and hyper- 
esthesia, by greater liability to vomiting, by absence of the macular- 
petechial eruption of typhus and of the drunken, besotted aspect of the 
latter disease. In cerebro- spinal fever the patient suffers with photo- 
phobia and is liable to local palsies of the eye-muscles (strabismus) and 
to general convulsions. Convulsions do not occur in typhus except 
from a complicating nephritis or retention of urine. 

Urosmia is distinguished from typhus by the preceding history, by 
the absence of high temperature, and the presence of cedema of the face 
or extremities, a history of vomiting or diarrhoea preceding the stupor. 
The condition of the urine and the absence of eruption are the final 
tests. 

Pneumonia is distinguished by the frequent respiration and rela- 
tively slower pulse, and by the local physical signs and absence of 
eruption. 

Typhoid fever is distinguished by its slow onset and marked ab- 
dominal symptoms. The eruption of typhus is petechial, and comes 
out on the fourth day ; that of typhoid fever consists of rose spots, and 
appears on the seventh or eighth day. 

Relapsing* Fever. 

An acute infectious and contagious fever, occurring in epidemics and 
characterized by the sudden onset of a febrile period lasting five or 
Seven days, which is followed by an intermission lasting usually a week, 
and this in turn by a relapse lasting three days. Its development is 
favored by filth and famine, but the specific cause is believed to be the 
spirillum of Obermeier, which is constantly present in the blood during 
the febrile stage. 

The stage of incubation lasts from five to eight days (Pepper), during 
which the patient may complain of malaise, lassitude, and flying pains. 

The invasion is sudden. It is evidenced by a chill or chills, frontal 
headache, pains in the back and limbs, vertigo, and great physical 
weakness. The temperature rises very rapidly, reaching 105°, 106°, 
or even higher, in the first day or two. The face is flushed, epistaxis 
sometimes occurs, the headache and other pains persist, but delirium is 
not common. The appetite is usually lost, thirst intense, the tongue 
coated white but moist, the bowels constipated. A mild catarrhal jaun- 
dice is not infrequent. Pepper states that nausea and vomiting are 



THE INFECTIOUS DISEASES. 



737 



prominent symptoms, the matters vomited at times containing blood. 
Tenderness, with pain in the epigastrium, is frequently complained of. 

The urine is scanty, high-colored, and frequently contains albumin 
and casts ; when jaundice exists it contains bile pigment and some- 
times blood. 

There is no peculiar eruption in relapsing fever, but in this, as in 
other fevers, erythemata, petechia?, and sudamina may be present. 

The pulse is often very frequent and soft, and hsemic murmurs may 
be audible. 

The objective symptoms are few. They consist of the flushed face, 
sometimes with slight jaundice and epistaxis, tenderness in the epigas- 
trium, with moderate enlargement of the spleen and liver, and consider- 
able cutaneous hyperesthesia, with tenderness along the nerve trunks. 
Bronchitis and sometimes hypostatic congestion of the lungs, with their 
usual physical signs, may be present. 

These symptoms continue without much change until the fifth or 
seventh day, when a decided crisis occurs. Sometimes this is deferred 
until the tenth day. The temperature within twelve hours falls from 
106° or 108° to or below normal ; the pulse diminishes in frequency 
from 120 or 130 to 60 or 70 ; vertigo, headache, and other pains disap- 
pear as by magic. The crisis is marked most frequently by a profuse 
sweat, sometimes by diarrhoea, epistaxis, metrorrhagia, or intestinal 
hemorrhage. The patient now enters upon convalescence without fever, 
and apparently makes rapid strides toward complete recovery. On the 
seventh day from the crisis, however, a sudden relapse occurs, with a 
repetition of the symptoms of the primary attack. The temperature 
may be higher and the febrile symptoms more severe, but the duration 
is shorter, lasting only three or four days. The spirilla, which disap- 
peared in the apyretic interval, are again found in abundance. A sec- 
ond crisis, with its associated symptoms, now occurs. The spirilla again 
disappear, and in the majority of the cases there is no further bar to 
complete recovery. A second, third, and even a seventh relapse may 
occur, as in a case recorded by Pepper. Organic lesions are not usually 
left behind, unless they have occurred as complications ; but even in 
ordinary cases the patient is left weak, ansemic, and with poor circu- 
lation. 

Spirillum Obermeieri. Found in the blood of persons suffering from 
relapsing fever during the paroxysms. 

Slender, flexible, spiral or wavy filaments from 16 to 40/" by 0.1 
Stains with aniline colors and Loffler's blue. (See Plate L, Fig. 4, A.) 

Aerobic and motile. Has not been cultivated on artificial media. 
When injected into the blood of men or monkeys produces typical 
relapsing fever. 

The most frequent complications are on the side of the lungs, kidneys, 
and heart. Lobar pneumonia is the most frequent. The heart becomes 
weakened by the very high fever and thrombosis, or sudden failure 
results. Embolism is very frequent. Suppurative parotitis, abscess of 
the spleen, profuse epistaxis, abortion in pregnant women, and neuritis 
deserve mention. 

Relapsing fever occurs at all ages, but is most common in adults. 

47 



738 



SPECIAL DIAGNOSIS. 



The duration varies according to the number of paroxysms. If there 
is only one it is about eighteen days. Under the name " bilious 
typhoid " a maliguant form of relapsing fever has beeu described. It 
is characterized by inteusity of the symptoms of the ordinary form, and 
by bilious or bloody vomiting, jaundice, and delirium, or by collapse, 
with purple nose, a small, frequeut, weak pulse, rigidity of the abdom- 
iual muscles, tenderness in the epigastrium, and cold, clammy skin. In 
some of the cases described by Graves, intussusception of the intestines 
was fouud after death. In other cases uraemia is au active factor. 

Diagnosis. The earlier cases in an epidemic may not be recognized, 
unless the blood be examined, until the occurrence of the characteristic 
relapse. It is most likely to be mistaken for typhus fever, which occurs 
under similar conditions. The aspect of the two diseases is very differ- 
ent. In typhus there is a heavy, stupid, sometimes besotted expression, 
with slight redness of the eyes and a contracted pupil. The patient lies 
oblivious of his surroundings, with low muttering delirium and ataxic 
symptoms. In relapsing fever, on the other hand, the sensorium is 
rarely much disturbed, the spleen and liver are enlarged, and there is 
hyperaesthesia. Moreover, in typhus there is a spotted eruption, later 
becoming petechial. In relapsing fever this is absent. 

Variola. 

Variola, or smallpox, is a specific infectious and contagious fever, 
beginning abruptly with chill, high temperature, headache, vomiting, 
sweating, and intense pain in the back. On the second or third day of 
the disease a characteristic shot-like, papular eruption appears, the pap- 
ules rapidly developing first into vesicles and then into pustules ; with 
the appearance of the rash the temperature falls, but rises again toward 
the end of the week in the pustular stage (fever of maturation or sup- 
puration). The contents of the pustules are discharged, crusts form, 
and are cast off about the eighteenth day. The disease may be accom- 
panied by a number of complications, particularly hemorrhages into 
the skin (purpuric smallpox), and from the mucous membranes (hem- 
orrhagic smallpox), both forms being popularly called black small- 
pox. For convenience of description the disease may be divided into 
four stages : (1) Incubation, (2) invasion, (3) eruption, (4) desquama- 
tion. 

Incubation. This stage lasts from ten to fourteen days, and is 
usually unaccompanied by any symptoms except malaise toward its 
close. 

Invasion is abrupt, and is marked by chilliness or a distinct rigor, 
headache, severe pain in the lumbar region, and sometimes delirium or 
convulsions, especially in children. The most prominent symptoms are 
the excruciating headache and backache. The temperature usually 
rises rapidly to 104° F. or higher in the first twenty-four or forty-eight 
hours. Headache and backache continue ; there is pain in the epigas- 
trium, a coated tongue, loss of appetite, nausea or vomiting, constipa- 
tion and copious perspiration. Prostration is extreme. Erythematous 
eruptions are not uncommon, especially on the inner surfaces of the 



THE INFECTIOUS DISEASES. 739 

legs and thighs. Petechia? also are found in Simon's triangle, whose 
base is at the umbilicus and apex at the knees. 

The stage of invasion lasts generally three days ; but it may be short- 
ened to two in very severe cases or lengthened to four in very mild 
ones, and in complicated and hemorrhagic cases it merges into the 
stage of 

Eruption. The characteristic eruption of smallpox appears first as 
minute specks resembling flea-bites. These in two or three days develop 
into small papules which feel like shot under the skin. In a day or 
two more the papules become vesicles, which at first contain a clear 
fluid, but which rapidly becomes turbid ; they are umbilicated. In the 
course of another day or two the vesicles have become pustules and are 
globular in shape. The period of ripening or maturation, when pustu- 
lation is at its height, lasts about three days; it is characterized by a 
marked secondary fever, the temperature rising as high as, or higher 
than, in the onset of the disease. The pustules now begin to dry up 
(desiccation) aud form dry scales or scabs which are cast off toward the 
end of the third week of the disease (eighteenth day); when the pustules 
have been deep enough to involve the true skin, characteristic scars 
called pits are left. 

No. 140. 





M 


































■_ 


■ 


- 


E 


■I 




E 






E 










:. 








E 








6 




■-. 








E 




E 


104- 
































































































































































































































k 








































































































































































io 3 _ 




















































































































































































































































































































f 






































































































































































































































































102— 
































- 
























































































i 




















































































































































































































































101 
















y 














































































J 












































































\r 




























































(1 


































































1 






































































































li- 




\ 


















100— 






















































































































































'A 


































V 
















































p 




































































































? 


















) 














































































/ 






























































































































99- 


















































































































































































A 






































































































1 


































4 


























































98 J 


1 


























































1 


































Pulse 


































































Date 




5 0 


10 


11 






13 


14 




10 


1 




18 


19 


SO 


■21 


•2 2 


•2:: 


24 








3 






•is 


■2':, 


30 


31 






:? 



Temperature in smallpox. Adult : mild case. 

The eruption appears first on the forehead, along the margin of the 
hair, and in the scalp, then over the rest of the face, especially about 
the nose and lips, subsequently progressing over the rest of the body 
from above downward. The eruption is most abundant upon the face 
and hands, often being confluent here when discrete elsewhere. The 
face may appear horribly swollen, bloated, and disfigured, and both face 
and hands are extremely painful from the great distention and the pus- 
tules, which are really small dermal abscesses. 

Varieties. Three varieties of variola, depending upon the number 
and disposition of the pocks and upon the presence of complications, are 
recognized: (1) Discrete; (2) confluent; (3) malignant. . 



740 



SPECIAL DIAGNOSIS. 



In discrete variola the pocks are Dot numerous, and are separated 
from each other by intervening healthy skin. 

In confluent smallpox the pustules are close-set, occupy almost the 
whole body, and coalesce, so that the face looks as though covered with 
a black, rough mask; the mucous membranes also are covered. The 
symptoms of the invasion are intensified and the eruption may appear 
before the third day. Patients are liable to suffer with profuse saliva- 
tion, uncontrollable vomiting, or diarrhoea (especially iu children), and 
with delirium which is often violent and destructive. The face is 
dreadfully swollen and the eyelids may slough ; the feet and limbs also 
may be swollen and painful. There may also be severe bronchitis and 
pneumonia, abscesses, extensive sloughing, and a pysemic condition. 

Malignant, or black, smallpox is a form in which the blood is so 
altered that hemorrhages into the skin or from the mucous membranes 
occur. In the former case there are petechias and ecchymoses upon the 
skin ; in the latter more or less profuse hemorrhages occur from the 
womb, kidney, bowels, lungs, and stomach. The mind of the patient 
remains clear and he is conscious of his peril. The eruption is delayed 
or does not occur at all. 

Varioloid is a mild form of smallpox occurring in a person protected, 
but not completely, by previous vaccination, or in a person who, from 
other causes, does not possess the average susceptibility. It is charac- 
terized, apart from its mildness, by great irregularity in the develop- 
ment of the symptoms. The initial symptoms, as a rule, are as severe 
as in ordinary smallpox. Prodromal eruptions, especially the erythe- 
matous, are very common. The eruption may appear first on the face, 
or on the chest and trunk, and later upon the face. The fever subsides 
with its appearance. The eruption passes from the papular to the 
vesicular stage, as in ordinary smallpox ; but here the process, as 
a rule, ceases, the vesicles drying up on the fifth or sixth day of 
the eruption. If pustules form they do not reach their full develop- 
ment. The eruption is always discrete. There is usually no secondary 
fever. 

Diagnosis. When fully developed, smallpox will not be mistaken 
for any other disorder. In the initial stage, however, there may be 
doubt whether the disease will prove to be pneumonia, cerebro-spinal 
meningitis, or typhus. If the patient has been exposed to smallpox 
and is unprotected by vaccination, and he is suddenly seized with chill, 
high temperature and excruciating pain in the lumbar region, there is 
great probability in favor of smallpox. If the patient has complained 
of headache, pains in the ankles and other joints, and is seized with 
a severe rigor, explosive vomiting, and great weakness of the limbs, the 
chances favor meningitis in the absence of known exposure to smallpox. 
In pneumonia, vomiting, chill, and high temperature succeed each other, 
but excruciating backache is wanting, and, on the other hand, the respira- 
tion is increased out of proportion to the pulse, and even in this early 
stage there may be cough and roughening of the respiratory murmur 
on one side. 

Typhus fever begins abruptly with chill and high temperature ; but 
the eruption which comes out on the third day is macular and petechial, 



THE INFECTIOUS DISEASES. 



741 



the temperature does uot fall, the aspect of the patient is drunken and 
stuporous, the conjunctivae are injected, the eye ferrety, the skin dry, 
hot, and biting to the touch (calor mordax). 

In the papular stage of the eruption it may be mistaken for measles ; 
but the red, swollen, blear-eyed, photophobic little patient with measles, 
with the characteristic coryza and obstinate cough, presents a very dif- 
ferent appearance from that seen in variola. Moreover, the eruption 
of measles is relatively flat, smooth, and velvety ; that of smallpox is 
acuminate, hard, and shot-like. The temperature in smallpox falls as 
the eruption appears; that of measles remains high and even increases. 
The papules of measles do not develop into vesicles. 

In the vesicular stage varioloid may be mistaken for chicken-pox. In 
the latter the eruption is practically vesicular from the start, occurs 
without prodromata, appears first upon the chest and neck, later upon 
the face and scalp, is usually very scanty, and rarely becomes umbilicated 
or pustular. There are, however, severe forms of varicella in which 
fever, restlessness, and cough precede the appearance of the rash, which 
is copious, some of the vesicles being inflamed at the base, some umbili- 
cated, and some with purulent contents. These cases are most common 
in scrofulous children whose hygienic surroundings are bad. In such 
cases the diagnosis cannot be made from the eruption. A consideration 
of the following points must decide : 1. History of exposure to vari- 
cella, on the one hand, or smallpox on the other. 2. The presence or 
absence of evidence of effective vaccination. 3. The age of the patient: 
smallpox occurs at all ages, varicella only in childhood. 4. The dis- 
covery among other neighboring children of unmistakable varicella or 
varioloid. 

Varicella. 

Chicken-pox is an acute specific infectious fever, occurring almost 
exclusively in children, and characterized by the appearance in succes- 
sive crops of colorless or pearly vesicles, which dry up and are shed in 
from two to five days. It is attended with very little constitutional 
disturbance. 

The incubation is generally about two weeks, but may be one or three 
weeks. In ordinary cases the first evidence of the invasion of the dis- 
ease is the appearance of the eruption. In other cases, the severer ones, 
the child may be noticed for some hours or several days to be indis- 
posed, complaining of loss of appetite, nausea, headache, and vague 
muscular pains. The fever is almost always moderate — 100° to 101°. 

The eruption consists of hypersemic macules, compared by Trousseau 
to the rose rash of typhoid fever. These rapidly become first papules 
and then vesicles. The papules are not hard as in variola. 

They appear first upon the chest, neck, face, and scalp, then upon the 
trunk and limbs. The development of the vesicles is so rapid that the 
eruption appears vesicular from the start. The vesicles vary in size 
from a pin-head to a small pea. They are very superficial, and usually 
rest upon a base that is slightly or not at all hypersemic. The contents 
are at first watery, but subsequently become pearly. The reaction of 
the fluid is alkaline. Distinct umbilication is rare, and pustulation 



742 



SPECIAL DIAGNOSIS. 



still more rare, but both occur. Almost always the vesicles dry up and 
form scabs, yellowish or brownish, which drop off leaving a slightly 
reddened, sometimes depressed spot. Sometimes the vesicles are to be 
seen upon the buccal mucous membrane and upon the throat. While 
most of the eruption appears in the first or second day, fresh vesicles 
continue to appear for several days. 

Desiccation usually occurs by the fourth or fifth day, and may be 
present in the first day or two. Often all stages, from the initial macule 
to the dried scales, can be seen in one case. 

Usually the vesicles are widely scattered, a dozen or two over the 
entire body. They are most numerous upon the back, and may be as 
close together as in discrete variola. 

In scrofulous and badly nourished children the lesions are more 
inflammatory and pustules are more common. If they are scratched, 
ulceration ensues. A gangrenous form has been described by Eustace 
Smith and others ; the cases are apt to be fatal. 

In ordinary cases during the eruption the child is rarely more than 
indisposed ; complications are rare, and the prognosis most excellent. 
The physician is not often consulted except to have his opinion as to the 
diagnosis. (For the differential diagnosis from smallpox, see Variola.) 

From vesicular and pustular eczema it is distinguished by the fever, 
the symmetrical grouping and discrete character of the lesions, the 
comparative absence of itching and burning, and its shorter course. 

Impetigo is distinguished by the absence of fever, the more local 
character of the eruption, and the fact that it is generally pustular. It 
is more common upon the face and hands than is varicella. 

Measles. 

An acute specific infectious and highly contagious fever, character- 
ized by coryza and bronchitis, a red papular eruption coming out on 
the fourth day and followed by a branny desquamation about the ninth 
or tenth day. The mucous membranes are especially liable to complica- 
tions. 

Measles occurs in epidemics, especially in cold weather, but individual 
cases are met with in large cities at all seasons of the year. It is so 
contagious that when one case develops in a household or institution 
almost every person exposed to it and not protected by a previous attack 
acquires it. Children from one to five years of age are most suscep- 
tible to the poison, but it may occur in utero and in old age ; moreover, 
the same person may have several attacks, showing that one attack does 
not afford the same protection as in scarlatina and variola. 

Measles is sometimes found in association with scarlatina and varicella, 
but it is especially liable to occur after pertussis. 

The specific cause of the disease has not yet been isolated. 

The period of incubation lasts from eleven to fourteen days. During 
this time the patient may exhibit no symptoms, or may be irritable and 
restless, with disturbed sleep and occasional cough, and looseness of the 
bowels. 

The invasion is marked by redness of the eyes and lacrymatiou, 



THE INFECTIOUS DISEASES. 



743 



sometimes with photophobia, sneezing, and an irritating, watery discharge 
from the nose, subsequently becoming inuco- purulent, and by cough 
and fever. In short, the early symptoms are those of a severe coryza. 
These symptoms last from three to five days (generally four) before the 
eruption appears. But the eruption is commonly visible upon the base 
of the uvula and soft palate, as raised, discrete dark-red papules, several 
days before it appears upon the body. The temperature rises duriug the 
first day to 100° to 102°, or higher if the case is to be a severe one. 
The bowels frequently are inclined to be loose and the passages some- 
what greeuish. The temperature falls on the second day to normal or 
nearly normal, and then steadily rises until it reaches its acme with the 
full development of the eruption, when, in uncomplicated cases, it falls 
rapidly to normal. With the coming out of the eruption the coryza 
increases in severity, and cough is a prominent and annoying symptom. 
It consists of a series of five or six explosive efforts without expectora- 
tion. In several cases the cough is almost incessant, so that rest is 
much interfered with. It depends upon a catarrhal inflammation of 
the entire respiratory tract, from the nose to the bronchioles. 



Fig. 141. 





^_ 








E 








t 




E 


































































- 






ic 4 - 
























































- I. 






























•4- 




i 






103- 
















\ 




h 








P 
































k 








102- 


















J 




















































































IOI- 














I 




















100- 



































Measles. Temperature taken on the first day made higher as the result of 
school and exertion. 

Objective Symptoms. The eruption on the body appears first about 
the neck, face, and wrists, and spreads gradually in two or three days 
over the entire body. It is usually most copious upon the face, which 
is swollen, dark-red in color, and closely set with papules, which are 
elevated, rounded at the summits, and feel like soft velvet to the touch. 
When to this picture is added that of a severe coryza with muco-serous 
exudate, which often glues the eyelids together and oozes out upon the 
face, and a corresponding condition of the nasal orifices, the physiog- 
nomy is at once seen to be peculiar. At this stage, moreover, photo- 
phobia is often considerable, the child burrowing its head in the pillows 
to escape light. 

The eruption is not apt to be confluent upon the body ; here the dark- 
red, elevated, smooth papules are very distinct. Sometimes they are 
grouped so as to form crescentic outlines. The eruption fades in the 
order in which it appeared, and is followed by a fine branny desquama- 



744 



SPECIAL DIAGNOSIS. 



tion. With the completion of the eruption the fever falls rapidly to 
or below normal, the coryza and bronchitis improve correspondingly, 
and in forty-eight hours convalescence is fully established. 

Complications. The complications of measles affect for the most part 
the mucous membranes of the respiratory and digestive tracts. The bron- 
chitis, which is always present, may become capillary, or be associated 
with oedema or with areas of catarrhal pneumonia. These are the most 
frequent and the most dangerous complications. Pneumonia may develop 
while the eruption is coming out, in which case the eruption is delayed 
or the spots have a dusky or bluish hue (black measles). More com- 
monly, perhaps, pneumonia is discovered when, the eruption being com- 
plete, a crisis should occur. 

Epistaxis is not usually dangerous. Profuse diarrhoea is very ex- 
hausting and delays the evolution of the eruption. Severe conjunctivitis, 
sometimes with ulceration of the cornea, is not uncommon. Otitis media 
occurs oftener as a sequal than as a complication. Noma, or cancrum 
oris, is a rare complication of measles occurring in ill-fed, badly nour- 
ished children. It is frequently fatal. 

Convulsions may occur as a complication, especially when pneumonia 
is developing. 

Sequelae. In cases in which there has been diarrhoea, measles is 
sometimes followed by considerable weakening of the digestive power. 
The catarrh of the respiratory tract, which almost invariably accom- 
panies it, predisposes to the development of whooping-cough and tuber- 
culosis. 

Paralysis may follow measles. It may be central or peripheral in 
origin, but generally is of the hemiplegic type; cases of acute polio- 
myelitis, acute ascending paralysis, and disseminated myelitis have also 
been reported. 

Varieties. Measles without catarrh is rare. It cannot be recognized 
from a measles-like rash seen in rotheln, except by the occurrence of 
other cases of undoubted measles. 

Measles without eruption is to be recognized by the coryza, possibly 
with eruption on the soft palate, the course of the temperature, and the 
exposure to specific infection of an unprotected person. 

Black measles is the name given to malignant forms in which, owing 
to complications, particularly pneumonia, the skin is dusky and the 
eruption comes out poorly and has a bluish color. In rare instances 
the eruption shows a hemorrhagic tendency, the spots being livid or 
ecchymotic. Actual hemorrhages from mucous surfaces may occur, the 
patient dying in coma or convulsions. 

Scarlatina. 

An acute specific contagious and infectious fever, characterized by 
a sudden onset, with vomiting, sore-throat, and high fever, followed in 
twelve or twenty-four hours by a bright-red, punctiform eruption, by a 
very frequent pulse, by a desquamation which is often in large flakes, 
by a very variable degree of severity, and by a large number of com- 
plications and sequelae, especially nephritis and inflammation of serous 
membranes. 



THE INFECTIOUS DISEASES. 



745 



Scarlet fever preferably affects children from one to five years of age. 
The liability to it diminishes after the tenth year ; but it is very rare 
under the age of six months. Puerperal women are very susceptible 
to the poison, and the existence of open wounds favors infection. 

The disease occurs in epidemics at longer intervals than is true of 
measles. Cases are most numerous in the autumn and winter months. 

The peculiar poison is doubtless a living organism, but it has not 
been isolated as yet. It is very tenacious of life, being capable of in- 
fecting, through clothing in which it has been retained, months after the 
clothing absorbed the poison. 

Few diseases vary so greatly in severity in different cases and in 
different epidemics. It may be the mildest or the most malignant of 
diseases. 

The period of incubation is remarkably short, generally from, three to 
five days ; but it may be a few hours, and in exceptional cases six days. 



Fig. 142. 





M 


t 








E 


M 


E 














































































i 


























A 




















104- 






























































W 




1 


















103- 








y 
















































0- 




























102— 




















































































































0— 




























IOI — 
















A 
























































7 












































100- 




















J 


























































































































Pulse 
















Date 

















Scarlet fever. Mild attack ; intense eruption. 



The invasion is abrupt. It is very common to be told that a child 
was apparently well on going to bed, but awoke in the middle of the 
night, vomited profusely, and complained of sore-throat. The child is 
found in the morning with a temperature of 103° or 104°, a pulse of 
120 to 140, and a scarlatinal eruption beginning to show upon the neck 
and upper part of the chest. Closer observation in such cases might 
have discovered that the child was feverish on going to bed, and that 
he had been somewhat chilly before that. Onset with decided chill, 
vomiting, and nervous symptoms indicates a severe case. 

The subjective symptoms of scarlatina are few ; they consist usually of 
pain in swallowing, with stiffness of the neck muscles, some headache, 
thirst, malaise, and a moderate amount of weakness. In the eruptive 
stage the skin itches, burns, and is frequently hypersesthetic. 

The objective symptoms and their order of succession are very charac- 
teristic. Vomiting is the rule, except in mild cases, aud hence is of 
importance in diagnosis, especially in otherwise doubtful cases. The 



746 



SPECIAL DIAGNOSIS. 



temperature is high at the onset, frequently 103° or 104°. It falls a 
degree or so in the morning ; but in the following evening, when the 
eruption is usually at its height, rises to 104° or 105°, and then 
gradually falls to normal in the course of a week, in ordinary cases. 
(Figs. 6 and 142.) 

The pulse rate is characteristically frequent, being 120 to 160 oftener 
than slower. This frequency is not an indication of danger. 

The throat exhibits a uniform flush extending over pharynx, tonsils, 
soft palate, and sometimes forward on the hard palate, nearly to the 
teeth. Sometimes darker red points can be distinguished on the soft 
palate. The tonsils are inflamed and project toward the median line 
from each side. Frequently the mouths of the follicles are blocked by 
a creamy-white exudate. It is not uncommon to find a severe follicular 
tonsillitis at the first visit. 

The tongue is at first covered with a thick, creamy fur, through 
which enlarged red papilla? show. The coating soon disappears from 
the tip, leaving it bright red — the " strawberry tongue." 

The shin is hot and dry. The characteristic eruption usually appears 
within twenty-four hours, often within six to eighteen hours, of the chil- 
liness or vomiting which marks the onset. Sometimes it comes out very 
slowly, seeming to be just ready to appear, but not appearing in its full 
development for four or five days. 

The intensity of the eruption varies from a scarcely perceptible 
erythema to the color of a boiled lobster. Usually its intensity varies 
with the severity of the disease. In ordinary cases the patient appears 
to be covered with a uniform red efflorescence ; but a closer inspection 
shows that there are darker red spots between which the skin is more 
or less erythematous. It is first seen about the ears and neck, and 
spreads with great rapidity, covering the entire body in a day. It is 
most intense upon the trunk and flexor surfaces. Upon the extensor 
surfaces the punctate character is better seen. Pressure causes the red- 
ness to disappear, but it immediately reappears. The physiognomy of 
the disease is peculiar. The circle about the eyes, nose, and lips remains 
pale, while the rest of the face may be fiery red. Itching and burning 
are annoying symptoms at times. 

The eruption fades gradually, in ordinary cases disappearing, except 
when there is pressure or irritation, toward the end of the week. Pap- 
ular and vesicular forms are also seen. 

It is succeeded by desquamation, which is extensive in proportion to 
the intensity of the eruption. The flakes are larger than in measles, 
and in severe cases the epidermis may come off in long strips. About 
the hands and feet this shedding is sometimes so great as to be compared 
to a glove. This stage may be protracted for several weeks, danger of 
infection lasting as long as desquamation continues. 

The urine is at first scanty, high-colored, and febrile. Later, when 
desquamation is in progress, there is great liability to albuminuria as a 
complication. 

Varieties. In addition to the ordinary form already described scar- 
latina exhibits many irregular forms. There may be only a sore-throat 
or follicular tonsillitis. If a rash is present it is very faint, and hence 



THE INFECTIOUS DISEASES. 



747 



easily overlooked. The diagnosis in such cases must be made from the 
fact of exposure to infection and the appearance of the throat. The 
occurrence of vomiting is very important in the diagnosis, as it is rare 
in ordinary pharyngitis and tonsillitis. Often such cases altogether 
escape detection until possibly a dropsy from scarlatinal nephritis indi- 
cates their nature. 

Severe diarrhoea may prevent the eruption from developing upon the 
skin. It appears upon the fauces, and the diagnosis is based upon this, 
the pulse, and temperature, and the fact of exposure. 

In scarlatina anginosa the strength of the poison is spent upon the 
throat. Pain is great and deglutition difficult. The tonsils are greatly 
swollen, so as almost to occlude the fauces, and their surfaces are covered 
with creamy exudate. The cervical glands are swollen and there is a 
tense and brawny cellulitis. Sometimes the tonsils become gangrenous 
and the cervical or submaxillary glands suppurate or become gan- 
grenous, with resulting pyaemia and death. Suppuration may extend 
to the ears and maxillary sinus. In this form, also, a false membrane 
is sometimes found upon the fauces — post-scarlatinal diphtheria. It is 
probably not due to the bacillus of Loffler, but to a streptococcus. 

In malignant forms the attack is ushered in with chill, followed by 
hyperpyrexia, convulsions, marked ataxic symptoms, or stupor. The 
profound blood disturbance is shown by the dusky hue of the eruption. 
Some patients lie in coma vigil, others are very restless and delirious. 
Vomiting and diarrhoea are sometimes superadded. Patients may 
emerge from this condition and succumb later to a nephritis or to grave 
anginose symptoms ; but death in a few days is the rule. In rare cases 
the dose of poison is so enormous that death takes place in a few hours, 
without the appearance of any eruption. 

Complications and Sequela?. The severe local symptoms mentioned 
under the anginose variety, together with convulsions, hyperpyrexia, 
and ataxic symptoms, may properly be regarded as complications. 
Apart from these the most frequent are nephritis and endocarditis or 
pericarditis. Nephritis generally appears with the beginning of des- 
quamation. It is nearly as frequent in mild as in severe cases, proba- 
bly because the danger of exposure to cold is greater in the former, 
although the scarlatinal poison unquestionably has a selective affinity 
for the epithelium of the kidney. The symptoms do not differ from 
those of acute parenchymatous nephritis occurring under other circum- 
stances. In some cases there are weakness, languor, slight fever, and 
prolonged convalescence; in others, oedema, anuria, convulsions or 
coma from uraemia. Endocarditis is often preceded by tenderness and 
soreness of the muscles and joints — scarlatinal rheumatism. 

Endocarditis and pericarditis develop in the course of the fever, 
giving rise to an increase or continuance of the fever, to local pain or 
dyspnoea, and to the usual physical signs. 

Pleuritis and meningitis also may occur. Much more common com- 
plications are otitis, peripheral neuritis, and affections of the joints, 
grouped as scarlatinal rheumatism. Paralyses, peripheral and central 
in origin, are occasional sequels of the disease. Scarlatina is found also 
in association with other diseases. 



748 



SPECIAL DIAGNOSIS. 



Diagnosis. Sudden onset, rapid rise of temperature, persistent 
vomiting, and sore-throat lead to suspicion of this affection. The 
characteristic eruption and its mode of evolution, the rapid pulse, the 
peculiar tongue, the circle of pallor on the face, are characteristic of the 
eruptive stage. The desquamation is an important diagnostic feature. 
Scarlet fever is distinguished from measles by the mode of onset, which 
is sudden, with chilliness, high temperature, vomiting and sore-throat, 
and great rapidity of the pulse ; whereas the onset in measles is 
gradual, with coryza, cough, moderate fever, perhaps looseness of the 
bowels, but no sore-throat. The eruption of scarlatina occurs on the 
first day, that of measles on the fourth ; the former consists of dark- 
red spots with intervening erythematous skin, the whole looking at a 
distance like a uniform bright-red flush ; the latter consists of raised, 
rounded, or flattened spots or blotches, velvety to the touch, and upon 
the body and extremities being grouped in patches with crescentic out- 
lines. The temperature in scarlatina subsides gradually after the rash 
is at its height ; that of measles increases until the eruption is complete, 
then subsides by crisis. The rash of scarlet fever persists for six or 
eight days ; that of measles fades as soon as it is complete on the fourth 
day. In the former, desquamation is in flakes or large strips : in 
the latter it is branny and nearly invisible. Scarlatina involves by 
preference the serous membranes and kidneys ; measles, the mucous 
membranes and lungs. 

Scarlatina has to be differentiated from pharyngitis, tonsillitis, and 
digestive disturbances attended with vomiting, high temperature, and 
occasionally erythematous eruptions. 

In ordinary pharyngitis and tonsillitis the redness is more apt to be 
confined to the pharynx, tonsils, and arches of the soft palate ; in 
scarlatina it extends as a flush over the soft and hard palate and buccal 
surfaces. In the former, high temperature, a very frequent pulse, and 
vomiting are unusual ; in the latter they are the rule. 

The glands of the neck also are more apt to be involved in the latter. 

In acute gastritis there is a history usually pointing to indiscretion 
in eating, with constipation. The pulse is not so frequent as to suggest 
scarlatina, sore-throat is absent, and any erythema present lacks the 
characteristic dark-red points, and is not followed by desquamation. 

The diagnosis from rubella is difficult at times. It differs from scar- 
latina in presenting mild catarrhal symptoms, sneezing, suffusion of the 
eyes, and cough, with a relatively fleeting eruption. The latter perhaps 
appears most frequently first upon the back and chest. Often the erup- 
tion is the first thing noticed amiss with the child. It more commonly 
resembles measles than scarlatina, but when it resembles the latter most 
it is more apt to be discrete than scarlatina and to be of a darker red. 
There may be a very intense rash without much constitutional disturb- 
ance, the temperature being lower and the pulse much slower than 
would be expected in a scarlatina presenting the same appearance. 
Nausea may be present, but vomiting is very rare. The post-cervical 
and post-auricular glands are more commonly enlarged in rubella than 
in a mild scarlatina, though this symptom is not invariable. 

Diphtheria is distinguished by its gradual onset, patches of false 



THE INFECTIOUS DISEASES. 



749 



membrane developing upon the fauces early. In angiuose scarlet fever, 
with severe follicular tonsillitis, the differential diagnosis is essentially 
the same as between simple follicular tonsillitis and diphtheria (which 
see). In addition, the pulse and temperature have a much higher range 
in scarlatina. The erythema of diphtheria is distinguished from the 
eruption of scarlatina by its fleeting character and the absence of 
desquamation. 

Grave cases w T hich begin with repeated vomiting, convulsions, de- 
lirium, and insomnia simulate meningitis; but a satisfactory cause for 
the latter is lacking, while the excessive heat of the skin, sore-throat, 
very frequent pulse, and early eruption clear up the diagnosis. 

So, also, the onset with vomiting, convulsion, and high temperature 
resembles pneumonia ; but in the latter the respiration is proportion- 
ately more frequent than the pulse, with altered breath and percussion 
sounds, while sore-throat and eruption are wanting. 

Rubella. 

Rubella is an acute specific contagious and infectious fever, charac- 
terized by a gradual onset with moderate fever, sore-throat, and slight 
coryza. The eruption, which appears without prodromata, usually 
resembles measles more than scarlatina. The duration, however, is 
shorter, the disease milder, and complications are rare. 

The disease is amply proved not to be a hybrid of measles and scarlet 
fever. The incubation period varies from one to three weeks, but 
is generally about two. As a rule this period is passed without symp- 
toms. 

The invasion is without prodromata, or none more definite than 
languor and indisposition, the first thing noticed being the eruption. 
This in some cases consists of pale-red, smooth, slightly raised blotches, 
closely resembling measles, but more pronounced on the trunk, and 
discrete. This is probably a very rare form. More commonly it con- 
sists of rose-red macula? or papules, occasionally confluent but usually 
discrete, and most marked upon the trunk. In still other cases the 
eruption closely resembles that of scarlatina, differing chiefly in being a 
paler red and accompanied by less heat of skin. Sometimes the erup- 
tion is circumscribed, as upon the face or limbs. It is usually the seat 
of considerable itching, and this may be the first symptom that attracts 
the patient's attention. It will be seen then that the eruption is multi- 
form in character. Concurrently with the eruption, there is usually 
slight rise of temperature to 100°-101°, suffusion of the eyes, with 
slight lacrymation and photophobia, and slight pharyngitis ; nausea is 
not uncommon, but vomiting is very rare. Higher temperatures have 
been recorded in a few cases, and so have nervous symptoms such as 
delirium and convulsions, but they are chiefly interesting as very excep- 
tional possibilities. On the other hand, the disease may run its course 
without any fever. 

The eruption extends over the body in twenty-four to thirty-six 
hours, less rapidly than in scarlatina, and pales much more quickly, 
fading on the portions of the body first attacked before reaching its 



750 



SPECIAL DIAGNOSIS. 



height on the last, and being completed in three or four days. Some- 
times a branny desquamation succeeds. 

In addition to the mild coryza and eruption, the most important 
objective symptom is swelling of the cervical glands, all of them some- 
times being swollen, especially those behind the sterno-mastoid, the 
auricle, and along the margin of the hair. This adenopathy, however, 
cannot be relied upon exclusively in the differentiation from scarlatina 
and measles, as Griffith has pointed out. 

Rubella has few complications : bronchitis, pneumonia, and otitis occur 
rarely, and still more rarely false membrane on the throat, and albumin- 
uria. The prognosis is excellent. It ends almost iu variably in recovery, 
except in very feeble children. 

Pertussis. 

Whooping-cough is a specific catarrhal inflammation of the respira- 
tory passages, involving especially the trachea and bronchi, and char- 
acterized by paroxysms of cough, which are succeeded by spasmodic 
closure of the glottis and a peculiar whoop. The disease occurs espe- 
cially in childhood, is contagious and infectious, and is sometimes 
epidemic. Whooping-cough may be conveniently divided into three 
periods : 

1. The catarrhal stage. 

2. The spasmodic stage. 

3. The stage of gradual subsidence of the disease. 

First Stage. The patient appears to have an ordinary cold. The 
amount of redness of the mucous membranes of the eyes, nose, and 
throat varies considerably, but there is not much discharge from the 
mucous surfaces. The cough is dry, and sometimes a riuging quality 
can be detected. The patient has slight fever, is irritable, has dimin- 
ished or capricious appetite, and restless sleep. A mild bronchitis of 
the larger tubes can be detected by physical exploration. 

The cough gradually becomes more frequent and paroxysmal, the 
eyes are red and suffused, and there is a muco-purulent discharge from 
the nose. The face often looks slightly swollen, especially about the 
upper part of the face and beneath the eyes. 

The Second Stage. Transition from the first to the second stage is 
marked by the appearance of the characteristic whoop. The paroxysmal 
cough is made up of a series of rapid expiratory efforts, diminishing in 
force and duration ; when these cease, there succeeds a prolonged crow- 
ing inspiration — the whoop. There may be only one paroxysm of 
coughing at a time, but more commonly, and always in severe cases, 
one paroxysm is succeeded by another. During the coughing, the 
child's eyes become suffused, the tears overflow, and there is a discharge 
of serum or muco-pus from the nose and of saliva and bronchial secre- 
tion from the mouth. The face becomes swollen and dusky. If the 
child is walking about it catches some object for support during the 
paroxysm; or if old euough, rushes for the water-closet or a basin, be- 
cause the seizure usually terminates in vomiting. The matters vomited 
consist of tenacious mucus and the contents of the stomach. With the 



THE INFECTIOUS DISEASES. 



75J 



mucus there may be streaks of blood, and occasionally there is pure 
blood. Daring severe paroxysms, hemorrhages are liable to occur; 
these are generally small and most frequently submucous. In well- 
marked cases, when the disease has continued some time, the face has a 
characteristic appearance : it is swollen, sodden, and dusky, with dull, 
heavy, red, and watery eyes. There is often ulceration of the lingual 
frsenum. 

The number of paroxysms varies from two or three to twenty or 
thirty or more in twenty-four hours, and they are worse at night. 

The whoop, while characteristic, is not present in every case, being 
absent especially in babies and very young children. Sometimes 
children have " choking spells " without much coughing and without 
the whoop. Again, when pneumonia or measles occurs as a com- 
plication, the whoop usually ceases for the time, but may reappear 
later. 

Third Stage. The third stage is less well defined than the first two. 
It may be said to begin when the nocturnal exacerbations become less 
frequent and severe. The number of paroxysms during the day dimin- 
ishes, and vomiting is a less frequent accompaniment. Appetite begins 
to improve, and the child begius to gain in flesh and to pass more rest- 
ful nights. 

The duration of the disease is variable. - Ordinarily it lasts from six 
to eight weeks, but it may be prolonged for several months. The 
patient is liable, whenever he catches a fresh cold, to a temporary return 
of the spasmodic cough, sometimes with the whoop. 

The great majority of the cases occur before the sixth year, and most 
of these between the second and fourth years. 

Influenza. 

Influenza is a specific contagious febrile disease, occurring in wide- 
spread epidemics, having a very short period of incubation, and charac- 
terized by great prostration, marked nervous symptoms, and catarrhal 
inflammation of the respiratory or gastro-intestinal tracts, or both. 
There is great liability to relapse, and to complications, which are 
generally pulmonary. 

The disease generally begins with the ordinary symptoms of coryza ; 
but the headache over the eyes and root of the nose is more severe, and 
may be so agonizing as to mask all other symptoms. The lacrymation, 
rhinitis, and tormenting cough are all usually worse than in ordinary 
coryza. Physical weakness, weariness, and depression of spirits are 
almost invariably present, and they sometimes reach an extraordinary 
degree. Fever is usually moderate (100°-102°), but may be 103° to 
104° for several days, and then gradually subside. In ordinary cases 
the patient seeks relief first for the headache, severe aching in back and 
limbs, and extreme weakness ; and if these are relieved is apt to com- 
plain most of incessant racking cough, often due more to a tracheitis 
than to bronchitis. Nausea and vomiting are not uncommon, especially 
in the morning, at which time also the patient frequently feels worse 
than he does later in the day. Sleep is unsound and unrestful, and 



752 



SPECIAL DIAGNOSIS. 



may be accompanied by drenching perspirations. Severe neuralgic 
pains are common. 

In some cases the disease attacks the stomach and bowels especially, 
and vomiting with diarrhoea are the prominent symptoms. In others 
the predominant symptoms are nervous, and great pain with prostration 
mask any catarrhal symptoms. Torpor and delirium may be present. 
Sometimes a prolonged and severe attack of asthma marks infection in 
susceptible persons. 

Influenza has proved itself to be a disease in which considerable care 
is required in prognosis. To a person in ordinary good health, with 
proper care, it rarely proves fatal ; but in the aged, or in those weak- 
ened by disease, especially of the lungs or heart, it is very grave, chiefly 
by causing capillary bronchitis or pneumonia, and by inducing heart 
failure. Less frequent complications are nephritis, otitis, cutaneous 
eruptions, swellings of joints, meningitis and neuritis. 

The duration of the disease is from a few days to a few weeks. Con- 
valescence is remarkably tedious, and is characterized by persistent 
weakness. Sweats are often annoying during this time. 

The heart often continues for some time to beat too frequently and to 
be easily excited by exertion. Relapses are common. 

Diagnosis. Influenza in the great majority of the cases is easily 
recognized. In certain cases, however, it has to be differentiated from 
pneumonia, typhoid fever, and cerebrospinal meningitis. 

Cases in which the disease sets in with high fever and marked chest 
symptoms are very apt to be mistaken for pneumonia. But the head- 
ache and prostration are more intense, while the respiration is not so 
frequent. Sweats are common, and albumin and casts in the urine are 
by no means rare. Physical exploration shows that both lungs are 
involved, though often not to the same degree. Resonance is impaired, 
and auscultation shows moist crepitant and subcrepitant rales, which 
seem to be due to an oedernatous condition of the lung tissue associated 
with a diffuse bronchitis. A true lobar pneumonia is rarely present 
even as a complication. 

If diarrhoea be one of the symptoms, typhoid fever has to be excluded. 
This is extremely difficult in the first two or three days. As a rule, 
headache, backache, nausea, and sleeplessness are at this time greater in 
influenza, the spleen is not so much, if at all, enlarged, the diarrhoea 
can be checked, aud tenderness and pain in the right iliac fossa are 
absent. 

From cerebrospinal meningitis it can be distinguished by noting the 
fact that it begins with coryza ; whereas cerebro-spinal meningitis often 
sets in with chill, vomiting, and faintness ; the headache in the former 
is usually frontal, in the latter occipital and accompanied by stiffness of 
the back of the neck. Further, in cerebro-spinal meningitis there are 
often swellings of the joints, delirium alternating with coma, and in 
young subjects convulsions are common. 

Finally, it may be said that the pronounced diagnostic feature is the 
preponderance of general symptoms over local inflammations. The 
occurrence of undue exhaustion, extreme general neuralgias and myal- 
gias, and high fever, profuse sweats, without intense catarrh or inflam- 



THE INFECTIOUS DISEASES. 



753 



mation to account for them, is of the highest diagnostic significance. 
The presence of an epidemic, the contagious nature of the affection, the 
presence of the micro-organisms described by Pfeiffer, in the discharges, 
and the sudden onset, all point to the diagnosis of influenza. 

Mumps. 

Mumps, or epidemic parotitis, is an acute specific contagious disease, 
characterized by a sudden onset, with great swelling and pain in one or 
both parotid glands ; by short duration, and by rapid recovery. Or- 
chitis is liable to occur in boys over the age of puberty. 

It occurs most frequently in children under ten years of age, but it 
may occur at any age. Males are much more liable to it than females. 
Life in institutions or barracks appears to render persons more suscep- 
tible. Stomatitis or sore- throat is said frequently to precede it. 

The period of incubation is generally about two weeks, and is usually 
free from symptoms. The invasion is sudden, with chilliness, a rise 
in temperature, which is generally moderate (101° to 103°), and pain 
at the angle of the jaw ; the corresponding parotid rapidly begins to 
swell, and so does the adjacent cellular tissue. The whole space between 
the ear and neck bulges out, the jaws are fixed, and any acid liquid, as 
vinegar, which stimulates salivary secretion, increases pain. At times 
the submaxillary glands are involved instead of the parotids. The 
disease may be limited to one side, or involve the opposite side as the 
process in the one first attacked subsides. Rarely it is bilateral from 
the start. When the swelling has lasted from three to five days the 
fever subsides, and the swelling begins to disappear rapidly. At this 
time, however, the opposite side may be attacked, or the testicle become 
inflamed. Usually it is the right testicle. In girls and women the 
ovary or mamma is rarely inflamed. Resolution is extremely rapid, 
and usually is not followed by sequelae. Sometimes, however, deafness 
is left. In fact, sudden deafness sometimes announces the commence- 
ment of an attack. Atrophy of the testicle is an occasional result of 
the orchitis. 

Cerebro-spinal Fever. 

An acute specific infectious aud mildly contagious disease, sporadic 
and epidemic, characterized by evidence of systemic infection, and 
generally also by symptoms depending upon inflammation of the cere- 
bral and spinal meninges — particularly intense pain in the back and 
head, hypersesthesia, retraction of head and neck, delirium, coma, and 
convulsions. 

This disease, which is also known as epidemic cerebro-spinal menin- 
gitis and as spotted fever, is an infectious form of meningitis, probably 
of microbic origin. It appeared in the United States first in 1806. It 
was epidemic in Philadelphia from 1863 to 1865, and since then 
sporadic cases have been reported every year. 

It is most common in cold weather and in persons under fifteen years 
of age. The period of incubation is unknown, but is probably short. 
It is free from symptoms. The invasion of the disease is abrupt, 

48 



754 



SPECIAL DIAGNOSIS. 



although in some instances the patient may complaim of rheumatoid 
pains in the limbs or a joint, headache, and weakness. Usually the 
first symptom is a severe chill, which may awaken the patieut from 
sleep. In other cases the initial symptom is a convulsion. Then 
quickly follow repeated vomiting, intense headache, sometimes accom- 
panied with backache, and extreme prostration. 

The rise in temperature is moderate, and the pulse is as often slow as 
frequent (Stille). The face is pale and livid, expressing suffering, and 
the patient may toss from one side of the bed to the other, begging for 
some relief for his headache. The pain in the back becomes more 
severe, and root-pains dart in all directions, but especially into the 
limbs or joints, which may be swollen and tender to the touch ; in fact 
the w T hole skin is hypersesthetic and the reflexes are increased. The 
spinal muscles become rigid, and the head may be retracted. Less 
frequently the back is arched and trismus occurs. Delirium is common 
at night. It is often of a sportive type, the patient making absurd 
remarks, cracking jokes, or singing snatches of a comic soug. Delirium 
may alternate with tonic or clonic convulsions and with stupor. The 
appetite is poor, the bowels constipated. A remission may occur on 
the third day, with temporary improvement of the symptoms. 

As the attack progresses there may be strabismus, inequality of the 
pupils, and optic neuritis. Vertigo, tinnitus, and photophobia are 
common. Hyperesthesia and delirium persist. The pulse becomes 
more frequent and the fever continues. In favorable cases improve- 
ment now begins, the headache and root-pains lessening, and delirium 
and spasms becoming less frequent. In unfavorable cases the convul- 
sions may become more severe and end in fatal coma, or the patient 
may sink into a typhoid condition, with nephritis as a complication. 

The skin eruptions, which explain the name " spotted fever," are not 
always present and exhibit no constant character. Herpes labialis 
and petechia? are the most frequent; in other cases the eruption is 
macular or resembles that of measles. 

In the malignant form of the disease death occurs in a few hours or 
two or three days. Such cases are apt to arise early in an epidemic. 
The patient has a violent chill ; delirium occurs early ; the headache is 
less intense, or at any rate gives way rapidly to stupor and coma. The 
pulse is frequent and feeble ; there may be no rise of temperature, the 
skin being cool, clammy, and cyanotic. Local or general convulsions 
may occur. The eruption may be purpuric, and even ecchymoses occur. 
The urine is scanty and contains albumin and casts. 

Mild cases occur usually late in epidemics. They are characterized 
by severe aching iu the head, back, and limbs, nausea, vomiting, vertigo, 
and prostration. They closely resemble the nervous type of influenza, 
and would escape recognition except during an epidemic. 

An abortive form, ending in recovery in two or three days ; and an 
intermittent form, with exacerbations on alternate days, have been 
described. 

The duration of the disease is from a few hours to two or three 
months. In ordinary favorable cases there is decided improvement 
toward the end of the first week, and convalescence is established in 



THE INFECTIOUS DISEASES. 



755 



two weeks. It may become chronic and last for weeks, and, as already 
stated, may be fatal in a few hours. Relapses are common in some 
epidemics. 

The most frequent complications are on the part of the lungs and 
heart, particularly pneumonia and endocarditis or pericarditis. Pneu- 
monia often occurs so early that it is difficult to decide whether it is 
primary with marked nervous symptoms, or is only a complication of 
the cerebro- spinal fever. Nephritis also occurs. 

The most frequent sequels are deafness, blindness, headache, and 
local palsies. 

Diphtheria. 

An acute specific infectious and contagious disease, sporadic and 
epidemic, occurring especially in children from one to six years of age, 
and characterized by insidious or abrupt onset, with moderate fever, 
and the development upon the fauces or upon any abraded surface of a 
grayish-white false membrane, which has a tendency to extend, espe- 
cially to the larynx. The subsequent phenomena are those of stenosis 
of the larynx, toxaemia, with or without superadded uraemia or marked 
cardiac weakness ; it is further characterized by the liability to paralysis 
as a sequel. 

Diphtheria is spread by inhaling the expired breath of a diphtheritic 
patient, or breathing air which has been contaminated by the clothing 
of the patient or the discharges from his nose and throat. It may also 
be transmitted directly, as when a fragment of membrane is ejected by 
coughing and infects the mouth or eye of physician or attendant* 
Moreover, it is contained in the sewers of large cities where the disease 
is endemic, and it persists in damp cellars if they have once been in- 
fected. Hence sewer gas and cellar air may carry the disease. There 
is reason also for believing that a similar disease affects birds, fowls, and 
cats at times, and from them may be transmitted to man. 

The specific poison is the Klebs-Loffler bacillus and its toxin. 

While children from one to six years of age are especially liable to 
it, no age is exempt — neither the newborn babe nor the very aged. 

One attack does not protect a person completely against a subsequent 
attack. 

The period of incubation varies from a few days to two weeks, or 
perhaps longer in exceptional cases. As a rule it is less than a week. 
It is shorter when the poison is virulent, and when infection has been 
upon abraded surfaces. 

The onset in mild cases is deceptively free from positive symptoms. 
The child is languid, perhaps slightly chilly, and has a little fever, with 
thirst, impaired appetite, and discomfort in swallowing. Unless the 
nature of the trouble is suspected the child is not thought ill enough to 
be kept indoors. The throat is slightly inflamed, especially about the 
tonsils. The child may protest that there is no pain on swallowing. In 
from twelve to twenty-four hours from the onset, sometimes later, a 
grayish pellicle will be found upon the tonsils, and the cervical glands 
be swollen. 

In more severe cases the onset is with chill or chilliness, followed by 



756 



SPECIAL DIAGNOSIS. 



a rise in temperature to 102° to 104°, sore-throat, and sometimes vom- 
iting, though this is not so common as in scarlatina. Convulsions and 
delirium may occur if the fever be high or the case malignant, but they 
are not common. Disgust for food makes it difficult to nourish the 
patient. Headache, thirst, and aching in the back and limbs may be 
complained of. Prostration is often very pronounced from the first. 

Objective Symptoms. As pointed out by Buzzard and McDonnell, 
the patellar tendon reflexes are often abolished as early as the first day. 
The characteristic false membrane appears first as a grayish pellicle 
upon one or both tonsils, and spreads thence to the soft palate and 
pharynx. The membrane soon becomes thicker and whitish in color ; 
when fully developed it appears like white or grayish-white parchment, 
not lying loosely upon the surface, but imbedded in the mucous mem- 
brane, the inflamed swollen edges of which rise above the false mem- 
brane, surrounding it "as the crystal of a watch is surrounded by the 
rim" (J. Lewis Smith 1 ). As the membrane becomes older it may be 
brownish, or even blackish in color, if tincture of iron has been given. 
If it is forcibly torn from the underlying surface hemorrhage is excited 
and the membrane is re-formed. As the membrane loosens spontane- 
ously there is often marked inflammatory reaction at the edges of the 
surrounding mucous membrane, and in the tonsils there may be decided 
sloughing with a dark, gangrenous appearance. 

The temperature usually falls by the second or third day, but this 
does not indicate either a favorable or an unfavorable end. A tempera- 
ture but little above normal is not uncommon in profound toxaemia. 

Albumin is usually present early, and often tube-casts and renal 
epithelium also can be found. The submaxillary and cervical glands 
are swollen and it may be difficult to open the mouth sufficiently to 
inspect the throat. 

In. favorable eases the membrane ceases to extend after three or four 
days ; there is no extension to the larynx ; the urine is free from albu- 
min, or only slightly albuminous, and the pulse 100 to 120 and of 
good force. 

In unfavorable eases the membrane shows a tendency to extend, 
either upward into the nasal fossse, producing a thin, irritating, excori- 
ating discharge from the nostrils, and rendering mouth-breathing 
necessary. It may extend also to the ears through the Eustachian tube, 
or into the maxillary sinus. Or the extension may be downward into 
the larynx, producing laryngeal stenosis. This isaunounced by hoarse- 
ness, with rapidly increasing difficulty in breathing. Inspiration is 
high-pitched, noisy, and difficult; the patient brings all the accessory 
muscles of respiration into play, the alee of the nose play, the ribs are 
sucked in, and still he pants for breath. Every now and then a par- 
oxysm of coughing produces cyanosis. 

In other unfavorable cases the throat symptoms are not dangerous, 
but ursernia develops. The urine is scanty, contains a large amount of 
albumin, considerable blood, and numerous blood, epithelial, and granu- 
lar casts. There is oedema of the feet and puffiness of the eyelids. 

1 Keating's Cyclopaedia of Diseases of Children, 18S9, vol. i. 606. 



THE INFECTIOUS DISEASES. 



757 



There is apt to be repeated vomiting; convulsions followed by coma 
and death may end the scene, or the patient may slowly emerge from 
the dark valley. 

In still other cases the diphtheritic poison affects the heart. The 
pulse becomes feeble and very frequent, the first sound very faint ; acute 
dilatation of the right heart may occur. There may be faintness and a 
tendency to cyanosis on the slightest provocation, or attacks of sinking 
and faintness may come without warning ; in still other cases sudden 
exertion induces paralysis of the heart, and death. 

In some malignant cases the patient is overwhelmed by a large dose 
of the poison, and dies in from one to three days in collapse from acute 
toxaemia, without there being any special local symptoms to account for it. 
In others the false membrane extends rapidly over the fauces, pharynx, 
and nasal cavities to the larynx ; death occurs early from obstruction, 
or if postponed there is extensive sloughing, with death from secondary 
blood poisoning or septic pneumonia. 

In exceptional cases the membrane is primary in the nares or larynx 
or develops upon some abraded surface, as a burn, or in the vagina 
of a puerperal woman. It may also attack the mucous membrane of 
the eye or the seat of a recent operation. Diphtheria also occurs as a 
complication of other diseases, particularly scarlet fever. 

The most frequent sequelae are anaemia, albuminuria, and paralysis. 
The latter comes on in from one to two weeks after convalescence has 
set in, but it may appear much earlier, and in exceptional cases later. 
It may be marked simply by loss of the knee-jerk, which has been 
alluded to already in the symptomatology, or involve the palatal and 
pharyngeal muscles, causing nasal voice, difficulty in swallowing, and 
regurgitation of food through the nose, or there may be multiple periph- 
eral neuritis. 

The Pseudo-Diphtheritic Bacillus resembles the genuine in all 
respects, except that it is not pathogenic. It seems to be an attenuated 
form of the former. 

Loffler's or the Klebs-Loffler Bacillus. This is found 
in diphtheritic pseudo-membranes, especially in the deeper portions. 
It is not found in the blood. 

Morphology. A bacillus 2 to 3 p long by 0.5 to 0.8 p broad, straight 
or slightly curved, with very many irregular forms. 

Biological Properties. It is facultative auaerobic, non- motile, and 
does not liquefy gelatin. It multiplies by fission. Stains with Lof- 
fler's blue. Certain points are stained intensely, almost black. It 
grows in nutrient gelatin, nutrient agar, or bouillon, but best of all in 
Loffler's blood-serum mixture (see page 156) at 35°. (Death-point, 58°; 
ten minutes' exposure.) It forms large round elevated colonies, grayish- 
white in color and moist. There is no visible growth on potato. Milk 
is a good soil. (See Plate II., Fig. 4.) 

On inoculation it causes a diphtheritic pseudo-membranous inflamma- 
tion. 

It generates a very poisonous toxin. 

Diagnosis. Diphtheria is distinguished from ordinary pharyngitis 
by the presence of membrane. From follicular tonsillitis by the pro- 



758 



SPECIAL DIAGNOSIS. 



jecting mouths of the follicles containing a creamy white exudate. 
Later the exudate may cover the entire surface of each tonsil and be 
difficult to distinguish from false membrane. The points of distinction 
are that in the former the exudate lies, upon the surface and can be 
brushed off without force and without leaviug a bleeding surface ] 
whereas in diphtheria the membrane is imbedded in the mucous mem- 
brane and cannot be torn from it without force. A raised, red, inflam- 
matory border of mucous membrane at the junction of the patch is 
strongly suggestive of diphtheria. In tonsillitis there is no appearance 
of membrane upon the soft palate or pharynx. Furthermore, in ton- 
sillitis the onset is attended with more fever and pain in swallowing 
than in simple tonsillar diphtheria. The existence of albuminuria and 
swelling of the cervical glands indicates diphtheria, and the absence of 
knee-jerk is an important diagnostic sign of diphtheria. 

Erysipelas. 

An acute specific contagious and infectious disease, characterized by 
a sudden onset, with a bright-red eruption, usually starting upon the 
face near the nose or mouth, and tending to march, with raised 
border, over the entire face and invade the scalp. It is attended with 
burning heat of the skin and great disfigurement from swelling. 

The specific cause of erysipelas is the streptococcus erysipelatosus. It 
is carried to a slight extent by the air, and still more in the discharges, 
especially those of the nose. Repeated attacks occur in persons with 
chronic naso-pharyngeal catarrh, carious teeth, or a sinus. It is liable 
to attack persons with open wounds (surgical erysipelas), and puerperal 
women, producing in these cases sloughing and septicaemia. When on 
the body it spreads over a greater extent than when primary on the 
face, hence its name, " the red runner." It may pass from the heel to 
the thigh, and over the trunk, lasting for weeks. One attack does not 
protect against another, but in case there is any focus in which the 
streptococci linger it actually predisposes to another. 

The period of incubation is usually from three days to a week. Pre- 
ceding the invasion there can usually be had on close inquiry in facial 
erysipelas a history of sore-throat and some enlargement of the cervical 
lymphatics. The invasion is sudden and is marked by chill. The 
temperature rises rapidly to 104° or 105°, and in the next two or three 
days may rise still higher. Coincidently with the rise in temperature 
the portion of skin to be affected burns, tingles, is tender to the touch, 
and may be seen to be reddened. The redness increases in intensity 
and extent, while the skin is swollen and slightly oedematous. The 
part of the face to be affected is usually the cheek in close proximity to 
the nose, less frequently near the mouth and ear. The affected part is 
tender and the seat of burning or smarting pain. Vesicles and blebs 
often form when the inflammation is very intense. The redness dis- 
appears upon pressure, but quickly returns ; sometimes it has a dusky, 
purplish hue. A marked characteristic of the disease is its tendency to 
spread. In ordinary cases it involves one cheek, eyelid, and ear, and 
travels across the bridge of the nose to the other side. The inflamma- 



THE INFECTIOUS DISEASES. 



759 



tion is most intense when it is spreading ; the advancing margin is 
raised, tense, and brawny ; the line is thus sharply drawn between 
healthy and inflamed tissue. The loose tissue about the eyes swells 
enormously, both eyes are closed, the entire face swollen, red, and with 
vesicles and blebs here and there. Curiously the chin escapes. The red- 
ness and swelling begin to subside in the part first attacked before the 
process has reached its height on the opposite side. As a rule, facial 
erysipelas does not extend beyond the face, the scalp and neck being 
spared. The scalp, however, is more frequently affected than the neck ; 
occasionally it results in extensive cellulitis of the scalp, with the pro- 
duction of a septic constitutional condition and much local sloughing. 
The submaxillary glands are more or less enlarged, sometimes so much 
as to prevent the taking of solid food. While the erysipelas is extend- 
ing the fever continues and is sometimes alarmingly high. The pulse 
is frequent and soft. Nocturnal delirium is not uncommon in severe 
cases, and sometimes nausea and vomiting are frequent. The bowels 
are usually constipated. The urine is high-colored, frequently con- 
tains a small amount of albumin, and actual nephritis is liable to 
occur. 

In favorable cases of facial erysipelas the process is at an end in a 
week or less. It may be prolonged to two weeks, subsiding by crisis or 
lysis, and convalescence is usually rapid. The vesicles or bullae dry up 
into yellowish crusts and the epiderm is shed in large or small pieces 
according to the intensity of the process. 

Pneumonia and nephritis are the most frequent complications. 
Meningitis, pericarditis, and endocarditis also occur. Erysipelas may 
extend inward and involve the fauces, pharynx, and larynx, producing 
oedema and death from suffocation. 

Sequelce. If the scalp has been involved, falling of the hair occurs. 
The cervical adenitis may result in abscess ; chronic nephritis may result. 
Otitis media occurs occasionally, and so do keratitis and abscess of the 
eyelids. 

On the other hand, erysipelas is credited with causing the disappear- 
ance of lupus, chronic eczema, and sarcomata. 

Diagnosis. Herpes zoster of the face and forehead is distinguished 
from erysipelas by the fact that vesicles appear first, followed by 
erythematous redness, and that they are limited by the median line, 
and are preceded and accompanied by sharp neuralgic pain, whereas 
erysipelas affects both sides of the face, and vesicles .appear at the 
height of the disease ; the pain is much less in erysipelas. 

From dermatitis of various kinds it is distinguished mainly by the 
sharper febrile reaction, the raised border of the eruption, which begins 
first on one side and spreads to the other. Erysipelas is rarely equally 
intense upon the two sides. Dermatitis frequently is. The latter 
exhibits often a rough surface, whereas until vesicles appear erysipelas 
is smooth and shiny. 

Chronic erythematous eczema occurs in middle-aged and old persons, 
is afebrile, accompanied by little swelling but a great deal of itching, 
and runs a slow course. 



760 



SPECIAL DIAGNOSIS. 



Cholera. 

An acute specific infectious disease, endemic in parts of India, but 
occurring in epidemics elsewhere, characterized by the outpouring into 
the stomach and bowels of large quantities of a serous fluid resembling 
rice-water, which fluid is usually vomited and discharged from the in- 
testines. It is further characterized by an algid state of collapse and by 
painful muscular cramps. 

The specific poison of cholera is believed to be the comma bacillus of 
Koch, and its ptomaine* 

The native habitat of cholera is India, particularly in the neighbor- 
hood of Calcutta; here it is endemic and thence it is liable to spread 
in successive epidemic waves along the lines of travel by sea and land, 
over the whole world. It is scarcely, if at all, contagious; the poison 
is contained in the vomit and dejections, which contaminate the drink- 
ing-water, food, and clothing. It preserves its vitality for long periods 
of time in water, especially if slightly alkaline and containing vegetable 
matter, and in moist clothing, as rags. 

The period of incubation is probably short in the majority of cases, last- 
ing only a few days. Occasionally it is two weeks. There are usually 
no definite symptoms during this time, but there may be a sense of 
weakness, with loss of appetite and dyspeptic symptoms. 

First Stage. The first stage, that of premonitory diarrhoea, is better 
regarded as the beginning of true cholera. It is characterized by profuse 
watery stools of a yellow or light-yellow color, and alkaline in reaction. 
They are accompanied by a rumbling noise in the bowels, but are passed 
without pain. From six to a dozen of these passages occur in twenty- 
four hours. The patient feels faint and exhausted after them, and may 
suffer with nausea, but vomiting is not usual. In severe cases there 
may be cramps in the calves of the legs. The voice is faint and husky, 
thirst intense, the tongue white and moist. The temperature is normal 
or slightly depressed. 

This stage may last from two days to a week, depending upon treat- 
ment. In some cases it is wholly absent, and the patient is ushered 
abruptly into the 

Second Stage. This usually comes on during the night. The patient 
is seized with vomiting which is at first bilious, but the fluids rapidly 
lose all color and become like rice-water. The stools likewise resem- 
ble water in which meal has been stirred, or in which rice has been 
soaked — a semi-transparent fluid with particles of epithelium resembling 
rice floating in it. This fluid seems to well up and regurgitate rather 
than to be vomited from the stomach, and to gush in quantities of a 
quart or two from the anus. Sometimes vomiting and diarrhoea occur 
at once. The patient has unquenchable thirst, aud is tortured with pain- 
ful cramps of the toes, legs, belly, and diaphragm. As the discharges 
continue the patient becomes more and more exhausted; the nose is 
pinched and twisted, the eyes sunken, the lips bluish, and the whole 
body may shrink beyond recognizable proportions. 

The skin is cold and moist, the breath icy, and the temperature 



THE INFECTIOUS DISEASES. 



761 



under the tongue is sometimes as low as 78° to 80° F. In the vagina 
and rectum it may be normal or slightly above normal. The patient, 
however, often has a sensation of heat. The urine is very scanty, con- 
taining albumin and sugar, or it may be suppressed. The pulse is very 
small and feeble, 100 to 120. The mind is clear, but the patient is 
listless, answering questions in an extremely faint voice and with mani- 
fest effort. 

Third Stage. From this collapsed and algid condition the patient 
may slowly emerge, the skin becoming less cold, the cramps less severe. 
A return of the secretion of urine is a hopeful sign. The reaction, how- 
ever, may simply introduce a low typhoid condition, with fever, dry brown 
tongue, subsultus, low muttering delirium, and coma. 

In some cases serum is poured out into the stomach and intestines and 
is retained there. The patient may be seized while walking with dizzi- 
ness, faintness, extreme prostration, and early collapse. 

In other cases the patient is smitten down with profuse vomiting 
and purging, dying algid and collapsed in a few hours, no reaction 
appearing. 

In favorable cases the vomiting ceases, the stools become less frequent 
and are tinged with bile and have a faecal odor. The urine increases in 
volume, while the albumin diminishes. Convalescence is very pro- 
tracted. Anaemia, great dibility, feeble digestion, and sometimes ob- 
stinate diarrhoea delay complete recovery. Relapses are liable to occur. 

In other cases reaction brings improvement in the gastro-intestinal 
symptoms, but uraemia develops, death following in convulsions or 
coma. 

The most frequent complications and sequdaz are eruptions, chiefly 
erythematous, ulcerations and bedsores, parotitis, and a painful tetanic 
spasm of the flexor muscles of the hands, forearms, legs, and feet, 
occurring between the tenth and fifteenth days of convalescence (Stille). 

Diagnosis. The chief points in the diagnosis from other affections are 
the knowledge of exposure to cholera; the character of the vomit aud 
dejecta, Avhich contain the comma bacillus (for its detection see under Bac- 
teriology); the cyanosis ; the rapid development of collapse, with cold skin, 
icy breath, torturing cramps, and greatly shrunken visage and body, 

Cholera morbus differs in that the stools remain turbid with bile or 
faecal matter, or contain blood; they never present the rice-water ap- 
pearance. Moreover, the passages are frequently preceded by colicky 
pains. Cyanosis and collapse are extremely rare. The stools do not 
contain the cholera bacillus. 

Other forms of acute toxic gastro-enteritis, whether from ptomaine 
poisoning or from a corrosive poison, are to be distinguished by the his- 
tory, the difference in the character of the stools, and the comparative 
absence of painful cramps in the legs, of cyanosis, and of collapse. 

Bacteriological Diagnosis of Cholera. Koch remarks : ] As 
cholera resembles in cliuical symptoms cholera nostras, infantile cholera, 
certain forms of peritonitis, certain organic poisons, and poisoning by 
arsenic, it is important to attain some means of making a definite diag- 
nosis. 

1 Zeitschrift fur Hygiene und Infektionskrankheiten, 1893, vol. xiv., No. 2. 



762 



SPECIAL DIAGNOSIS. 



The 3ficroscopical Examination. Cover-glass preparations of the de- 
jections of the patient or of a flake of mucus from some fluid of the body 
are made. The preparation is stained by ZiehPs red (fuchsin). In 
addition to the cholera bacilli, the bacillus coli communis and other 
intestinal bacteria are found. The cholera bacilli lie in groups in the 
thread-like strands of mucus. They form in heaps, the bacilli lying in 
the same direction. Koch holds that this mode of grouping is charac- 
teristic and diagnostic. He further holds that if bacilli coli are in 
close proximity to numerous scattered bacteria resembliug the cholera 
bacilli, the case is one of Asiatic cholera. 

Peptone Cultivation. A small quantity of the dejection of some 
flakes of mucus is inserted with a platinum loop into a sterilized 1 per 
cent, peptone solution. The solution is maintained at 37° C. The 
cholera bacteria are aerobic, aud develop on the surface of the peptone, 
while the faecal bacteria remain in the deeper layers. As soon as the 
peptone is cloudy a drop from the surface is examined microscopically. 
Within six hours the surface is overwhelmed with a pure culture of 
cholera. Later they are mixed with bacteria coli. The examination 
should be made from six to twelve hours after the peptone solution is 
inoculated. The peptone solution should be strongly alkaline, and a 
1 per cent, solution of common salt added. Care must be taken to see 
that the solution contains sufficient soda. In plate cultivations the 
cholera bacilli are overwhelmed by the fsecal bacteria. 

Gelatin Plate Cultivation. Three dilutions are prepared and poured 
into double-bottomed vessels. The vessels must be submitted to a tem- 
perature which is warm, but does not liquefy the gelatin, as about 22° 
C. The colonies are seen in from fifteen to twenty hours. If the 
gelatin becomes liquid the cholera colonies resemble Finkler's bacteria. 

Agar Plate Cultivation. The growth is not so characteristic as it is 
in gelatin. The cholera bacilli form large colonies of a light gray- 
brown transparent appearance. Colonies of other bacteria are less 
transparent. The colonies can be obtained in from eight to ten hours 
after exposure to a temperature of 37° C. Microscopical examination 
of the colonies must be made. 

Cholera-red Reaction. Cholera cultivations contain indol and nitrous 
acid, and produce a red color if sulphuric acid is added. This color is 
produced by other bacteria also, but by none other of the bacteria that are 
curved. Care must be taken to make the cultivations with suitable 
peptone, and to have the sulphuric acid free from nitrous acid. 

Experiments on Animals. The agar cultivations are employed. They 
must be introduced into the abdominal cavity of the guinea-pig. The 
injection must not be made into the intestine, a matter which requires 
considerable practice. No other spirillum or curved bacillus produces 
the symptoms. 

Dengue. 

An acute specific contagious disease, occurring in epidemics and 
characterized by severe pains in the head, back, and joints, various skin 
eruptions, a prolonged convalescence, and a very low rate of mortality. 

The disease occurs in epidemics in tropical and subtropical countries, 



THE INFECTIOUS DISEASES. 



763 



and rarely in cooler climates. It derives its name, dengue (dandy), 
from the stiff and unnatural gait assumed by patients in convalescence. 
In the southern parts of the United States an expressive name given to 
the disease is " breakbone fever." 

The specific cause of the disease is believed by Dr. McLaughlin to be 
a micrococcus which he isolated. The period of incubation is short, 
varying, however, from a few minutes to several days, or even a week. 
Invasion is very sudden and is rarely preceded by any prodromata. It 
is marked by chilliness or a chill, and very severe pains in the head, 
back, and limbs. In children the onset may be by convulsions, which 
are sometimes followed by stupor and vomiting. The pains are some- 
times excruciating aud are accompanied by tenderness of the muscles; 
there is extreme debility. The temperature rises to 102° or 103,° but 
rarely is much higher. 

The pulse is frequent — 110, 120 or more. In from one to three or 
five days the temperature falls to or below normal (the remission), ac- 
companied by sweating or diarrhoea, and fluctuates about this level for 
several days, when a second and moderate rise in temperature, which is 
of short duration, occurs. During the first rise in temperature there 
is a transient, generally scarlatiniform, rash, which is not followed by 
desquamation. The urine is febrile, but not albuminous. During the 
remission eruptions — scarlatiniform, herpetic, urticarial, or like miliaria 
— begin to appear, accompanied by the secondary rise of temperature. 
The eruptions may be in successive crops and are followed by desquama- 
tion. Convalescence is now established, but may be interrupted by 
relapses. The most frequent complications affect the nervous system, 
but bronchitis and diarrhoea occasionally occur. 

Malarial Fevers. 

A group of fevers associated with the protozoan organism of Laveran, 
and characterized by periodic paroxysms of chill, fever, and sweat. 
They are not contagious, but can be transmitted by inoculation. 

Malarial fevers, while most prevalent in tropical and subtropical 
regions, are found also throughout the temperate zone, especially in 
autumn and spring. In Europe their favorite habitat is Italy, and in 
the United States the southern and southwestern States. Conditions 
that especially favor their development are marshes and swamps, fed 
partly by sea-water ; low ground along streams of slow current ; and 
freshly upturned soil. 

The poison is carried in the air, hence winds blowing from marshes 
or other infected districts are especially dangerous. 

The specific poison in malarial fevers is no doubt organic. The 
protozoan organism described by Laveran exhibits several different 
forms, which he regards as stages in the development of one organism, 
but which may be different species. Golgi maintains that there are 
several distinct varieties of parasites whose periodicity in development 
and sporulation corresponds with the different types of fevers. 

Intermittent Fever. This is a type of malarial fever in which 
the temperature remains normal between the paroxysms. A malarial 



764 



SPECIAL DIAGNOSIS. 



paroxysm is characterized by (1) chill, (2) fever, and (3) sweating, 
occurring in the order named and in immediate succession. The time 
between the beginning of one paroxysm and the beginning of the next 
is called the " interval," that between the conclusion of a paroxysm 
and the beginning of the next the " intermission." The interval varies 
in different forms of intermittent fever : in the quotidian there is a 
paroxysm every day, with an interval of twenty-four hours ; in tertian 
there is a paroxysm on alternate days, with an interval of forty-eight 
hours ; in the quartan there is a paroxysm every third day, with an 
interval of seventy-two hours. In double quotidian there are two 
paroxysms in the twenty-four hours, but not of the same intensity. 

In the double tertian there is a paroxysm every day, the first and 
third and second and fourth corresponding as to hour and intensity. 
That is to say, if there be a severe paroxysm at 10 a.m. Monday, there 
will be another severe paroxysm at 10 a.m. Wednesday, while on 
Tuesday and Thursday there will be milder paroxysms, but at another 
hour than 10 a.m. 

In the double quartan severe and mild paroxysms succeed each other 
every other day, but each third day is free from any paroxysm. 

While the rule is for malarial fevers to occur periodically at the same 
hour, the second paroxysm may occur an hour or two earlier (anticipa- 
tion) if the disease is growing worse, or an hour or two later (postpone- 
ment) if it is growing better. 

Quotidian intermittents are slightly more common than tertian ? 
while the quartan variety is rare. 

The incubation period probably varies widely, depending upon the 
intensity of the poison. As a rule repeated exposure is necessary to 
develop the disease in temperate climates. During this period the 
patient may suffer with headache, drowsiness, pains and aching in the 
limbs and back, constipation, a coated tongue, and thirst. 

The onset of a typical malarial paroxysm is marked by chilly sensa- 
tions, especially along the spine, accompanied by yawning and the 
development of "goose-flesh." Then a decided chill sets in, the 
patient shaking violently. The face is pale and pinched, the lips blue, 
the nose pointed ; as the chill becomes worse the teeth chatter, the whole 
body feels cold, the skin feeling rough, dry, cold, and harsh. The 
finger-nails and toe-nails are blue, the skin being wrinkled upon the 
palmar and plantar surfaces. The superficial bloodvessels are so con- 
tracted that a drop of blood is obtained with difficulty. The voice is 
thin and weak, almost inaudible. 

The volume of blood driven from the surface leads to congestion of 
the viscera, particularly the spleen, liver, and stomach. Nausea and 
vomiting are not uncommon. The spleen is perceptibly enlarged, and 
frequently the liver is also. 

Although the surface temperature is depressed, the internal tempera- 
ture is rising, and may be two or three degrees above normal. By 
degrees the severity of the chill abates and the patient asks to have the 
extra bed-clothing removed. Reaction has set in. The surface blood- 
vessels dilate and the skin becomes flushed. The temperature continues 
to rise, ofteu reaching 103° to 106°, pulse and respiration increasing 



THE INFECTIOUS DISEASES. 



765 



correspondingly in frequency. The patient complains of a throbbing, 
dizzy headache, and vomiting may recur. The bowels remain con- 
stipated. The temperature now begins to fall, and the sweating stage 
succeeds. Perspiration appears first upon the forehead, face, and neck, and 
by degrees extends over the rest of the body. The perspiration becomes 
more and more profuse, until the whole body is drenched with it. All the 
subjective symptoms vanish with wonderful rapidity, and the patient, 
with the exception of exhaustion, seems to be restored to complete 
health. The hot stage lasts from one to two hours, the cold stage from 
three to eight hours, and the sweating stage from two to six hours. 

Fig. 143. 



105- 



99- 



98: 



9 6: 



E M E M E M E 



Intermittent fever. Temperature every six hours. Morning and evening temperature 
and highest at chill. 



In the interval between paroxysms the patient is free from fever, but 
is amemic, weak, and has impaired appetite, and constipation. 

During the entire paroxysm the mind remains clear. 

The chief objective symptom, apart from the phenomena of chill, fever, 
and sweat already described, is the occurrence of plasmodia in the blood 
(see under Blood). 

Irregular Forms. Irregular forms of intermittent fever are more 
common in Philadelphia than the typical form just described. 

^ In the mild form the patient complains of great lassitude, irrita- 
bility of temper, and drowsiness during the day, but at night tosses 
upon his bed and gets up in the morning more tired than when he went 
to bed. The back and limbs ache, and feel as though they would give 
way under him. There is severe throbbing headache, with some dizzi- 
ness and faintness. The bowels are constipated, the tongue heavily 



766 



SPECIAL DIAGNOSIS. 



coated with yellow fur. The temperature is moderately elevated and 
the patient has great thirst. Nausea and vomiting are absent, though 
there is little desire for food. There may be a burning feeling referred 
to the splenic region. The patient is worse on alternate days, and the 
attacks may be preceded by slight creeping chills. On inquiry the 
patient will be found to live in a low-lying district near one of the 
rivers, or in a damp house over an unclean, moist cellar, or adjoining a 
place where fresh soil has been upturned. 

In the form known as " dumb ague" there is periodically great 
depression, with aching in head and limbs, a sensation of coldness 
rather than chilliness, but no marked fever and sweating. Nausea and 
vomiting may, however, be present. Da Costa says he has seen it 
manifest itself by excruciating pain over the kidney, and almost entire 
suppression of urine. There may also be severe paroxysms of gastral- 
gia. It is more common in old residents of malarious districts. 

In masked malarial fever the poison manifests itself in an attack of 
neuralgia, especially of the supra-orbital nerve and gastric nerves. 
Malaria may also be latent until some impairment of the resisting- 
power brings it to light. Hence it appears as a complication of pneu- 
monia and dysentery, and typhoid fever (constituting typho- malarial 
fever), especially in the southern and southwestern portions of the 
United States. Moreover, women who have previously had intermit- 
tent fever may suffer a recurrence following confinement. 

The essential points in the diagnosis of intermittent fever are the 
periodical recurrence of paroxysms of chill, fever, and sweating, or of 
attacks of dumb ague, or of paroxysms of neuralgia, without organic 
lesion, associated with the presence in the blood of pigment and plas- 
modia, and with enlargement of the spleen and possibly of the liver. 

Diagnosis. A typical malarial intermittent fever is not likely to be 
mistaken for anything else. (See Fever, page 112.) It needs, however, 
to be distinguished from septicemic fever, due to absorption into the blood 
of pus and the toxins produced by bacterial growth. Such fever occurs 
in tuberculosis, especially in the stage when cavities form and pus collects ; 
in the puerperal state, in empyema, subphrenic abscess, abscess of the 
liver, or it may occur in any form of suppuration. Here also, then, are 
recurring chills, with fever and sweating, but the attacks are not regu- 
larly periodical and intermittent ; sometimes the fever is intermittent 
and sometimes remittent, the chills recur at irregular intervals, and are 
not so violent as in the malarial attack. The essential difference, how- 
ever, lies in the fact that a local cause can be found to explain them, 
either tuberculosis of the lung or some other viscus, or a collection of 
pus in an organ or cavity, or a fcetid discharge from the womb, with 
local tenderness or peritonitis; moreover, the patient loses flesh more 
or less rapidly, his blood is free from malarial germs and pigment, and 
quinine does not control the fever. 

From the intermittent fever of hepatic origin (described elsewhere 
by the author) the diagnosis is more difficult, in that physical signs of 
any local trouble may be wanting. But the fever is not regularly in- 
termittent, is not controlled by quinine, but may be by measures 
directed to the origin of the trouble, and jaundice may be present. 



Fig. 144. 




K -J 



The first twelve figures show the malaria Plasmodium. It is a pale amoeboid body inside the 
red corpuscle. It increases in size at the expense of the corpuscle. In the last four of the twelve 
it is enlarged and contains pigment granules derived from the hsemoglobin. The figures of the 
fourth row show progressive stages in the process of cleavage of the Plasmodium and shifting of 
the pigment granules. In the fifth row the process of cleavage is seen to be completed, and final 
isolation of the spores has taken place. The dark granules are pigment granules. The last row 
shows oval parasites. — Laveran's corpuscles observed in atypical cases of malaria. (From Golgi, 
" Studien uber Malaria," Fortschritte der Medicin, Bd. iv., Tafel in.) 



768 



SPECIAL DIAGNOSIS. 



Urethral fever, occurring as the result of operations upon the urethra, 
or simply from the passage of a catheter or bougie, may be mistaken for 
malarial fever ; but the paroxysm is usually single, and the history of 
the operation and the absence of plasmodia from the blood clear up the 
diagnosis. 

Syphilitic fever is distinguished by a tendency for the chill, fever, and 
sweating to be nocturnal in recurrence, and by evidence of syphilitic 
infection coupled with absence of malarial germs from the blood. 



Fig. 145. 




A form of intermittent fever from syphilis. J. D., aged twenty-six. Secondary period. 
Mercury and iodide of potash relieved it. Observe that the pulse is not increased. 

Eemittent Malarial Fever. A type of malarial fever charac- 
terized by a remission instead of an intermission in the febrile parox- 
ysms. It is due either to a greater intensity of the malarial poison or 
to a different species of organism. It is much more rare in temperate 
climates than either quotidian or tertian intermittent and is attended 
with more gastric disturbance and a much larger mortality (twelve 
times greater, according to the statistics of the Civil War). 

The onset is more abrupt than in intermittent fever. Prodromata 
are not so common, but when they occur they are of the same character. 
The chill is not usually so violent, nor the cold stage so long as in 
intermittent fever ; on the other hand, nausea and vomiting are com- 
mon, and in some cases there are bilious vomiting and diarrhoea, ten- 
derness over the stomach and spleen, and jaundice also may be present. 
The temperature rises rapidly to 103° to 106° and remains high for a 
longer time than in intermittent fever, the hot stage lasting in severe 
cases from 6 to 18 or 20 hours. 

During this time the patient suffers from headache, pains in the 
back and limbs, great thirst, and gastric irritability. A remission now 
succeeds. The temperature falls two or three degrees, but not to 



THE INFECTIOUS DISEASES. 



769 



normal ; free sweating occurs, the nausea and vomiting cease, and the 
patient becomes much more comfortable. He may fall asleep from ex- 
haustion, but if awake is conscious of weakness, aching in the limbs, 
and perhaps nausea. In the course of some hours the temperature 
again rises, often to a higher point than before, but frequently without 
an antecedent chill. The same subjective symptoms are repeated, and 
another remission follows. Daily paroxysms usually occur, those on 
alternate days being severer. The temperature often reaches its highest 
point at the third paroxysm. The disease generally runs its course in 
from nine to twelve days, but it may last much longer. The type of 
fever may change to intermittent, which is a favorable sign, or become 
continued and again remittent, or remain remittent throughout ; finally, 
the fever may subside gradually, or, less commonly, by crisis. The 
urine is febrile but not albuminous. 

Pernicious Malarial Fever. This, as the name implies, is a 
form of malarial fever with destructive tendency. It is also called 
malignant and congestive fever. It may be intermittent or remittent. 
Nearly 24 per cent, of the cases occuring in the U. S. Army from May 
1, 1860, to June 20, 1866, proved fatal. 

Bemiss 1 divides it into three classes : (1) the algid, or congestive 
form ; (2) the comatose form ; (3) the hemorrhagic form. To this 
another class, (4) the gastro-enteric form, may be added. It is impor- 
tant to remark that the first paroxysm does not usually, in any of these 
forms, indicate that the type of the disease is pernicious. The first 
seizure may, however, prove fatal. 

1. The algid form, according to Bemiss, occurs more frequently than 
any other, its perniciousness being due to an aggravation of the cold 
stage of an intermittent attack. The patient is extremely weak, with 
cold extremities, pinched features, blue lips, and faint voice. Respira- 
tion is shallow, the pulse rather slow, feeble, and irregular ; the patient 
is further exhausted by vomiting and liquid, offensive diarrhoea, the 
passages sometimes being involuntary. There may be copious perspi- 
ration, but the internal temperature is very high. The mind may be 
clear, or deep stupor be present. Unless speedy relief can be afforded, 
the attack ends fatally. 

2. In the comatose form the patient is completely unconscious, the 
skin hot "and of a muddy, semi-jaundiced hue" (Bemiss). Both pulse 
and temperature are increased in frequency. In other cases coma is 
preceded by wild delirium, resembling acute meningitis. 

The comatose form is most apt to occur in those who continue to 
reside in a malarious region without proper safeguards against its 
poisonous influences. 

3. In the hemorrhagic form there has been, as a rule, previous altera- 
tion of the blood, the bloodvessels, and other tissues, by long-continued 
malarial poisoning or cachexia. Then, when intense congestion of these 
parts occurs as the result of the surface chill, hemorrhage follows. In 
some districts, however, and at certain seasons, there has been a special 
predilection of the poison for the kidney, with resulting hematuria. 



1 Pepper's System of Medicine, vol. i. 666. 
49 



770 



SPECIAL DIAGNOSIS. 



The prominent symptoms are a prolonged chill with high temperature ; 
nausea and vomiting, sometimes of a greenish-black fluid ; oedema of 
the lower extremities ; general anasarca and occasionally oedema of the 
lungs, and hydrothorax ; bloody and albuminous urine, with tube-casts; 
and intense jaundice. Pain in the right hypochondrium or over the 
kidneys is common. 

Bemiss asserts that uncomplicated malarial fever has not a hemor- 
rhagic tendency. 

4. The gastro-enteric form has for its prominent symptoms nausea, 
vomiting, diarrhoea, intense thirst, extreme restlessness, a frequent, 
feeble pulse, and urgent dyspnoea. " The breathing is deep-drawn ; to 
each expiration succeeds two short inspirations'' (Da Costa). The 
patient is cold and partly collapsed. Reaction may or may not occur. 

The patient may have several paroxysms of pernicious malarial fever, 
and succumb in any one of them. Convalescence is slow. The most 
frequent sequel re of malarial fevers are anaemia, neuritis and paralyses, 
and malarial cachexia. 

Malarial cachexia occurs especially in those who have lived for a long 
time in malarious regions. They may or may not have had typical 
malarial attacks. The patient suffers with dyspepsia and constipation, 
with occasional bilious attacks ; the face is of a pale lemon-yellow color, 
and may be slightly jaundiced ; there is marked anaemia, w T ith pigment 
and crescentic and flagellate forms of plasmodia in the blood ; together 
with great enlargement of the spleen (ague-cake) and some enlargement 
of the liver. The patient is weak and languid, and sometimes has con- 
siderable mental depression. 

Typhoid fever is distinguished from pernicious malarial fever by its 
gradual onset, the absence of chills and vomiting as a rule, and on the 
other hand, the presence of epistaxis, delirium and ataxic symptoms, 
tympanites and diarrhoea with pale-yellow watery stools, and rose- 
colored spots. The temperature in typhoid is more continuously high, 
the daily oscillations being of shorter range. A history of exposure to 
malarial infection and of previous attacks can often be obtained. The 
urine of typhoid exhibits the diazo reaction, that of malarial fever does 
not. 

Yellow Fever. 

An acute specific contagious miasmatic disease, endemic and epidemic 
on the tropical and subtropical shores of the Atlantic Ocean, character- 
ized by a sudden onset, a duration of a week or less, a characteristic 
facies, a fall in the pulse rate preceding a fall in temperature, and by 
albuminuria, jaundice, and vomiting, with a tendency to hemorrhages. 

Yellow fever is endemic in Havana and other seaport cities of Cuba, 
and in Rio Janeiro, Brazil. From these centres it is liable to become 
epidemic, and to be carried in ships and by persons and clothing to 
other places. In this way epidemics have developed in the seaports of 
the United States, especially in the south around the Gulf of Mexico, 
but sometimes as far north as Philadelphia and New York. The dis- 
ease becomes epidemic in the hot season and ceases upon the appearance 
of frost. The specific germ has not yet been isolated. 



THE 



INFECTIOUS 



DISEASES. 



771 



Id countries in which the disease is endemic it is the custom to regard 
the native children as immune. 1 Dr. John Guiteras, however, is 
strongly of the opinion that the disease is kept alive between epidemics 
by cases among these very children. He has also shown that it prevails 
among white children before it becomes epidemic among adults. 

The period of incubation varies from a few hours to two weeks. 
Guiteras states that the cases in which it extends beyond the seventh 
day are exceptional. 

The invasion is abrupt, and occurs usually in the night. It is marked 
by chilliness oftener than by a decided chill. The temperature rises 
rapidly to 102° to 103° or 104°, not often higher in favorable cases. 
The pulse is correspondingly increased in frequency at first, but very 
commonly begins to fall before the temperature, so that later the pulse 
is relatively slow. The face is peculiar and characteristic — it is flushed 
and somewhat swollen ; the eyelids are somewhat swollen, with red- 
dened edges ; the eyes are watery, glistening, and slightly but distinctly 
tinged with yellow ; the pupil is small and brilliaut. Guiteras says : 
" The appearance of the face is often sufficiently characteristic on the 
first day of the disease to warrant a positive diagnosis." He also says 
that these phenomena are often better observed at a slight distance than 
on close inspection. 

The tongue is large, moist, and coated with white fur. The stomach 
is irritable and the epigastrium tender. Nausea with repeated vomiting 
occurs. The fluid is at first of a light greenish-yellow, subsequently 
becoming decidedly bilious. The bowels are constipated. 

The urine almost invariably contains albumin at some time during 
the first three days. Its presence may be very transient. It may be 
found in the evening and not at other times. The amount of albumin 
is sometimes very large, and abundant blood and tube-casts are found. 
The nephritis subsides rapidly, without leaving traces. The urine is 
acid in reaction and scanty in amount. It is sometimes suppressed. 

During this febrile period the patient complains of headache, pains in 
the back and limbs, and intense thirst. The mind, however, is usually 
perfectly clear. Contrary to expectation, Guiteras asserts that the 
nervous symptoms are, perhaps, more prominent in the adult than in 
the child. u The loquacity, the short-cut phrases and precipitate 
speech, the excitement, the show of indifference with unmistakable 
evidences of fear — all these, that are such prominent features of the dis- 
ease in the adult, are absent in the young." 2 

In from two to five days the temperature falls to or below normal, 
headache and pains in the limbs disappear, and the patient is cheerful 
and thinks himself convalescent. This is the fact in mild cases, but in 
more severe cases there is a return of symptoms in a few hours or at 
most a day or two. The jaundice deepens, vomiting becomes more 
urgent and in adults is accompanied by much retching. It is bilious, 
streaked with blood, or thick and wholly black (" black vomit"); the 
temperature may rise again as high or higher than in the original 

1 " Report of the Surgeon-General of the Marine-Hospital Service, 1888 ;" Keating's Cyclopaedia of 
Diseases of Children, 1889, vol. i. 

2 Keating's Cyclopaedia, loc. cit. 



772 



SPECIAL DIAGNOSIS. 



paroxysm, or it remains depressed. In any event the pulse is apt to be 
slow, often from 40 to 60. The urine contains albumin, blood, and 
casts, and may be suppressed, adding uraemia to the other toxaemia. 
Convulsions at this stage are usually uraemia Hemorrhages may occur 
from any mucous surface. The gums are tender, swollen, and bleed 
easily. There may be epistaxis, hemorrhage from the ear, bowel, uterus, 
or vagina. Preguant women miscarry. Ecchymoses also may form. 
Death may take place in coma or convulsions. If the patient linger 
beyond the fifth or sixth day he sinks into a typical typhoid state, with 
diarrhoea and marked adynamia, from which he may or may not 
emerge. 

As in scarlet fever, the patient may be smitten down and die in a few 
hours from the time he was in apparent health. Iu other grave cases 
the temperature remains high, and rises iustead of falls on the third or 
fourth day. The duration of the disease is from two to five or six 
days ; if a typhoid state develop it may last ten days or two weeks. 

Complications are not common. Phlebitis and lymphangitis occur, 
aud Guiteras says he has noticed hepatitis, insanity, and paralysis 
(probably neuritis). Second attacks are extremely uncommon. 

Diagnosis. Yellow fever is distinguished from pernicious malarial 
fever by the slow pulse, the characteristic facies, the early transient 
albuminuria, the deep jaundice, the absence of diarrhoea, the occurrence 
of black vomit, the tendency to hemorrhage, and the clear mind. 

Actinomycosis. 

A specific infectious disease of cattle, occurring occasionally in man, 
attacking especially the lower jaw, lungs, and intestine, and character- 
ized by a long duration, by the development of tumors and metastatic 
growths, and by pyaemic symptoms. 

It is due to the actinomyces or ray fungus (see Pig. 146), which pro- 
duces in cattle the disease known as big or lumpy jaw and swelled head. 
The fungus is conveyed in the food or drink, and gains entrance to the 
body through abrasions in the mouth or a decayed tooth, or is inspired 
into the lungs. 

At the seat of invasion a slowly growing, slightly painful tumor 
develops. Bones are affected as well as soft tissues. These become 
swollen and suppurate, the fungus being at all times obtainable. The 
fungous masses appear to the unaided eye as particles of yellow sand, 
and are greasy to the touch. When the lungs are involved the symp- 
toms are those of purulent bronchitis or phthisis, actinomyces being 
found in the sputa. The masses which form upon the intestinal mucous 
membrane may lead to suppuration and perforation of the intestine. 
Metastasis to any organ may occur, with resulting local symptoms. 
The duration depends upon the organs involved in metastases. If 
these do not lead to early death, that result is brought about at the end 
of months or years by slow pyaemia, with resulting amyloid degenera- 
tion and its consequences. The prognosis depends upon early recognition 
and complete removal. 



THE INFECTIOUS DISEASES. 773 



Fig. 146. 




Case of actinomycosis. 



Glanders. 

An infectious constitutional disease, transmitted from horses to man, 
appearing in an acute and chronic form, and characterized by an erup- 
tion, ozsena, small tumors, ulcerations, cough, and death in coma or 
collapse in from one to four weeks in the acute form, or in three or 
four months in the chronic form, the symptoms in the latter resembling 
at times syphilis and at times tuberculosis. 

The disease is rare in man. It may be acquired by direct inoculation 
of an open wound with the pus from a glanderous ulcer or nasal mucous 
membrane, or indirectly from infected straw or other material. The 
raw meat of a glandered animal also has infective power. 

In acute glanders the onset is marked by headache, slight fever, and 
pains in the limbs. If a wound has been infected this becomes painful, 
swollen, and behaves like any poisoned wound. Sometimes a diffuse 
redness, resembling erysipelas, spreads from the infected point. Fagge 
refers to a case in which the first complaint was of pain in the side and 
dyspnoea, so that acute plenro-pneumonia was suspected. 

An eruption, consisting first of papules, which rapidly become flat 
vesicles and then pustules or bullae, appears in the first day or two, or 
sometimes not for a week or even longer (Fagge). The bullae or 
pustules rupture and give vent to a thin purulent discharge. 

There may be hard, painful lumps in the muscles, with subsequent 
suppuration (farcy). 



774 



SPECIAL DIAGNOSIS. 



Ozaena is not always present. It appears in the second or third week 
of the disease. It consists of a muco-purulent, then purulent, foetid 
discharge from the nose. The latter subsequently swells and becomes 
red and very painful. Ulcers and even necrosis of the septum are the 
lesions ; the same catarrhal condition may exist in the throat, eye, 
larynx, and mouth, accompanied at times with ulcers and false mem- 
brane. The patient gradually sinks into a septicemic condition, with 
irregular fever, dry brown tongue, albuminuria, delirium, coma, and 
collapse. 

The duration of the acute form is from one to four weeks. Only one 
in thirty-eight cases collected by Bollinger ended in recovery. 

In the chronic form there are ulcers upon the hand, face, forehead, 
or elsewhere. In other cases the lesions are abscesses in connection 
with joints which are followed by persistent fistulas. In still other cases 
there is a pustular eruption. Ozaena may or may not exist. In still 
other cases the prominent symptoms are cough, bloody expectora- 
tion, hoarseness, fever, and emaciation. Bollinger reports seventeen 
recoveries in a total of thirty-four cases of chronic glanders. 

Diagnosis. Acute glanders is distinguished from rheumatism by 
the history of the case, the occupation of the patient, the existence of 
an open, irritable sore, and the fact that while the joints may be 
painful, they are rarely red and swollen, as in rheumatism. Subse- 
quently the appearance of pustules, bulla?, and ozaena makes the case 
clear. 

The same peculiar features serve to distinguish it from pyaemia, 
malignant pustule, and other infectious diseases. 

In chronic glanders, as suggested by the Messrs. Gamgee, an ass or 
horse might be inoculated with the nasal mucus or pus from a farcy. 

Anthrax. 

Anthrax, malignant pustule, charbou, splenic fever, etc., are names 
given to an acute infectious disease derived principally from herbiv- 
orous animals, and characterized by the development of a pustule or 
boil, with extensive brawny oedema and subsequent toxaemia ; or tox- 
aemia may appear first and metastatic abscesses subsequently. The 
disease also attacks the gastro-intestinal mucous membrane and the 
lungs. 

Anthrax is caused by the anthrax bacillus and its toxins. Outside 
the body it forms endogenous spores, which are extremely tenacious of 
life, and to which infection is invariably due. They infect not only 
the carcasses of animals, but also the soil, all utensils used in the care 
of the animals or the soil, and they persist with infective power in the 
hides, hair, hoofs, and wool (" wool-sorter's disease"). It is possible 
that it may be transmitted to man by stings of insects, particularly 
flies and mosquitoes. 

The period of incubation varies from a few hours to several days. 
In the form known as malignant pustule the patient has a pricking or 
burning feeling, which may lead him to think he has been stung by an 
insect at some exposed part of the body, particularly the hand, face, or 



THE INFECTIOUS DISEASES. 



775 



neck. At the seat of irritation first a papule, then a vesicle, develops. 
The vesicle may attain considerable size. The contained fluid quickly 
passes from clear to bloody, and then escapes, leaving a dark-brown or 
black scab (anthrax). 

The original vesicle may be surrounded by a series of smaller ones. 
Instead of disappearing, the base of the vesicle becomes inflamed 
and indurated, the induration extending to surrounding tissue and 
causing a condition of brawny oedema. A whole arm or one side of 
the face and neck may be swollen. There may or may not be an 
associated lymphangitis. 

The general health does not suffer at first, but in a day or two fever 
sets in, accompanied with delirium, sweating, great weakness, enlarge- 
ment of the spleen, severe pains in the limbs, and diarrhoea. Death, 
preceded by collapse, may occur in from five to eight days (Fagge), or 
the tissue occupied by the pustule may slough out. 

Bollinger and others have called attention to anthrax oedema, in 
which there is no pustule but only a yellowish or greenish swelling of 
the tissues. It is seen most frequently in the eyelids. 

Anthrax of the gastro-intestinal mucous membrane, as described by 
Bollinger, presents the following symptoms : the patient first complains 
of malaise, loss of appetite, pains in the limbs, giddiness and headache. 
Then vomiting may set in, and a more or less severe diarrhoea, the 
evacuations often containing blood. There may be pain in the abdo- 
men, which becomes somewhat tumid ; the spleen is enlarged. Dyspnoea 
and lividity appear, with restlessness and with excitement or stupor. 
Epileptiform convulsions may occur, the upper limbs may be affected 
with tetanic spasms, there may be opisthotonos, and the pupils may be 
widely dilated. The pyrexia is slight, and death is preceded by ex- 
treme collapse. The duration of the disease is usually from two to seven 
days, but sometimes it is scarcely twenty-four hours. 

Still another form of anthrax occurs among the wool-sorters of Brad- 
ford, England ; it is characterized by intense dyspnoea and a feeling of 
oppression or constriction. Breathing is labored, but not much accel- 
erated. Only a few coarse rales are to be heard on auscultation. The 
expectoration may be abundant and bloody, or absent. There is a 
tendency to collapse, with cold bluish skin, and a subnormal axillary 
temperature. The rectal temperature, however, is raised two or three 
degrees. Death may occur in coma and convulsions, or suddenly, 
the mind being clear. The duration of the disease is from one to five 
days. Dr. Bell says that those who survive for a week generally 
recover. 

Bacillus Anthracis. This is found in the pus of the lesions of 
anthrax or malignant pustule. 

Morphology. A bacillus, 2 to 3 up to 20 to 25 p in length and 1 
to fi in breadth. The bacilli are often joined end to end in long 
threads, and these threads are massed together in bundles. As found 
in animals they are short rods with square ends. They stain best with 
Loffler's blue, but also with the basic anilines and by Gram's method. 
When in the stage of spore-formation the threads look like strings of 



776 



SPECIAL DIAGNOSIS. 



Biological Properties. It is aerobic, non-motile, and liquefies gelatin. 
(See Plate L, Fig. 2, a, and Fig. 147.) 

It grows best in neutral or slightly alkaline media (gelatin, agar, 
milk, meat-infusion, etc.) at 20°-38°. The growth-limits are 12° 
and 45°. 

Cultures on agar are quite characteristic, consisting of a dense central 
mass with twisting and crossing bundles all around it. In gelatin 
stab cultures a fine branching threadwork grows out alongside the 
puncture. The gelatin soon liquefies and the bacilli settle in white 



Fig. 147. 




Bacillus anthracis in the blood of a guinea-pig. X 1040. (Gjbbes.j 

masses. The growth is abundant on potato, and is grayish, dry, rough, 
and irregular. The virulence is attenuated by cultivation. Drying 
does not kill the spores. Very toxic substances are found in the cul- 
ture medium. When inoculated, the organism produces the pustule of 
anthrax. 

Anthrax bacilli are not so numerous in human blood as in that of 
the lower animals. They are most likely to be found in the spleen, 
which is apt to be much swollen. 

Diagnosis. In doubtful cases a mouse or guinea-pig should be in- 
oculated with the blood. Carbuncle is distinguished by its tendency 
to develop upon the back or shoulders, and other covered portions ; 
anthrax on uncovered portions. In carbuncle there is a series of 
openings resembling a sieve, filled with pus and plugs of necrotic tissue. 
In anthrax there is at first a central black crust. The boggy feeling 
of carbuncle is different from that of the brawny oedema of anthrax. 
Finally, in carbuncle, anthrax bacilli are not found in the blood. 

The intestinal and thoracic forms are distinguished by the occupation 
of the patients, the absence of other adequate cause, and the result of 
the blood examination. 

Foot-and-Mouth Disease. 

A specific infectious disease, communicated to man through cattle, 
sheep, or pigs, and characterized by a stomatitis. It is communicable 



THE INFECTIOUS DISEASES. 



777 



by milk ; the period of incubation is from three to five days. Invasion 
is characterized by slight fever, heat and soreness of the mouth, and 
the development of vesicles which burst and leave shallow ulcers. 
Saliva is freely poured out. The tongue swells greatly, and eating is 
painful. Vesicles sometimes appear about the fingers, but not upon 
the feet. The disease lasts from one to two weeks, and ends almost 
invariably in recovery. 

Hydrophobia. 

An acute specific disease communicated to human beings by the bites 
of animals similarly affected. The animals most frequently affected are 
the dog, fox, wolf, cat, and skunk ; 90 per cent, of the cases in human 
beings are due to dog-bites. 

The period of incubation is uncommonly long and very variable — 
from two weeks to two months usually. It is said in some cases to 
be a year or more. The disease has been divided into three stages — 
the melancholic, the spasmodic, and the paralytic. 

In the melancholic stage there is pain, hyperesthesia, or even reopen- 
ing of the healed wound. The patient is extremely depressed in spirits 
and may be irritable. He seems to be laboring under a constant tension 
of fear and keenly sensitive to light, sounds, or draughts. He is affected 
with thirst, but attempts to swallow water cause intensely painful spasm 
of the larynx. 

The second stage is reached usually on the second day. The laryngeal 
spasms are increased and lead to intense dyspnoea and to pitiable strug- 
gling and gasping on the part of the patient. In addition to the con- 
vulsive seizures, the patient foams and froths at the mouth, and his 
face expresses the extreme terror and mental anguish he feels. The 
second stage lasts from one to three days, and is followed by exhaus- 
tion intermitting with paroxysms of less severity. The patient may 
now be able to swallow easily, but there is great weakness of the heart, 
and death may occur from failure of the heart, from asphyxia, or in a 
convulsion. The duration, as indicated, is only a few days. The result 
practically is always fatal, but recovery may be possible. Bites of the 
face are the most likely to be fatal. 

The Plague. 

An acute specific infectious and contagious disease, occurring in 
epidemics, characterized by high fever, sometimes by petechia and 
other hemorrhages, and in cases which last long enough, by buboes. 
The death-rate is extremely high. 

The plague is a disease of the East, being endemic in some parts of 
India, but epidemics have occurred in Italy, Russia, Turkey, England, 
and other parts of Europe. 

The period of incubation is from two to seven days. The invasion 
is marked by lassitude, languor, headache, and dizziness. The stupid 
aspect and staggering gait may lead to the belief that the patient is 
drunk. Chill or chilliness soon supervenes, followed by fever, which 
often rises to hyperpyrexia, and is accompanied with unquenchable thirst, 



778 



SPECIAL DIAGNOSIS. 



aud sometimes nausea and vomiting. Delirium and a typhoid condition 
follow, with a marked tendency to failure of the circulation and collapse. 
If the patient survive until the second or third day, glandular swellings 
develop in the groin, or axilla, or angle of the jaw. Often they have 
to be sought for to be found. Sometimes they are prominent and are 
followed by suppuration and even ulceration. Carbuncles are much 
rarer manifestations than buboes. Petechia?, vibices, hemorrhages into 
the kidney, bloody vomit, occur in the worst cases. 

The duration is from six to ten days. If there is much suppuration 
convalescence is prolonged. 

Leprosy. 

A chronic specific infectious disease, characterized by the develop- 
ment of tubercles, anaesthetic patches, and neuritis, and followed by 
ulceration and destruction of tissue. The disease occurs especially 
from puberty to the thirtieth year, and oftener in men than in women. 
It develops slowly and insidiously. Sometimes the first skin lesion is 
a crop of bullae, suggestive of pemphigus. More commonly there 
appear reddish or violet- colored patches, varying in size from a quarter 
of an inch to two or three inches in diameter, and becoming of darker 
hue later. The next step is the formation of nodules, which are char- 
acteristic of the disease. These may develop upon the patches already 
described, or in other places. They vary in size from a pea to a bird's 
egg or larger. They are most common upon the face and extensor 
surfaces of the arms, legs, fingers, and toes. The tubercles consist of 
an infiltration into the true skin ; they are raised, firm, relatively pain- 
less, and vary in color from red to copper. The face is characteristi- 
cally distorted into a fierce expression (leontiasis). The tubercles may 
become absorbed and leave atrophic areas, but generally they break 
down into eroding ulcers, which slowly burrow and increase in extent, 
eating off portions of the nose, fingers, hands, and feet, and exposing 
muscles, tendons, nerves, bloodvessels, and bone. Tubercles form also 
upon nerve trunks and ulcers upon mucous membranes. 

In other cases or in combination with the tubercles are anaesthetic 
areas, especially upon the limbs and trunk. Ulcers may follow without 
the previous occurrence of tubercles. With the anaesthetic patches are 
associated crops of bullae and neuritis. 

The further peculiarities of the disease are its long duration; its 
slow progress interrupted by apparent recovery of some of the ulcers ; 
its afebrile course (the temperature is generally subnormal) ; its com- 
parative painlessness, and its slight impairment of the general health. 
Death results from gradual wasting, or is hastened by some intercurrent 
affection. 

The specific cause of the disease is probably the bacillus leprae of 
Hansen. It is found in the thin pus of the ulcers aud in the lesions 
themselves. It consists of rods 4 to 6 p long and 1 v broad, closely 
resembling tubercle bacilli. They may be distinguished by their yield- 
ing their color more readily, and taking easily aniline dyes in simple 
watery solution (Von Jaksch). (See Plate I., Fig. 4, b.) 



THE INFECTIOUS DISEASES. 



779 



The diagnosis from a tubercular syphilide is made by the history of the 
case, the possibility of infection, the bacteriological examination, the 
slow progress, and the inadequacy of specific treatment. The presence 
of anaesthesia and of neuritis points to leprosy. 

Miliary Fever. 

Miliary fever, or sweating sickness, is an infectious disease, occurring 
in epidemics, and characterized by moderate fever, profuse sweating, 
tenderness and a sense of oppression at the epigastrium, and a vesicular 
eruption. The disease has occurred epidemically in England, but is 
not met with now outside of France and Italy. 

After mild prodromal symptoms the disease sets in suddenly with 
moderate fever, profuse sweating, and epigastric distress, sometimes 
amounting to anguish. The characteristic eruption appears on the 
third or fourth day. It consists first of small reddish maculae, in the 
centre of which a vesicle develops. The latter varies in size from a 
pin-head to a pea. The contents are at first clear, but subsequently 
become purulent. Desiccation and desquamation follow. The erup- 
tion is most profuse generally upon the neck and trunk. Sometimes 
there are marked nervous symptoms and even convulsions and fatal 
collapse. 

It is distinguished from rheumatism by the moderate fever and 
absence of joint swellings, and from malarial fever by the absence of 
chills, of periodicity in the febrile movement, and absence of malarial 
organisms from the blood. 

The duration of the disease is from one to four weeks. The mortality 
in some epidemics has been very high, in others very low. 

Milk Sickness. 

An acute disease affecting cattle, and transmitted from them to human 
beings in the milk or meat. The disease is limited to a few sparsely 
settled localities west of the Alleghany Mountains. It is characterized 
by great debility, with muscular tremor upon motion (hence the name 
" trembles"), vomiting (hence "puking fever"), a peculiar foetor of the 
breath, obstinate constipation, and moderate fever or subnormal temper- 
ature. The vomited matters are said to be of a peculiar soapy material 
of yellowish or greenish color. The duration is usually less than a week. 
The patient may sink into a typhoid condition and die in coma, or he 
may die in a few hours. Convalescence is protracted. 

Trichinosis. 

An acute infectious disease, caused by absorption of trichina? spiralis, 
and characterized by gastric and intestinal irritation, followed by pain 
and stiffness in voluntary muscles, oedema of the eyelids, face, and feet, 
by profuse sweating, and by death or tardy convalescence. 

The trichinae are absorbed by human beings through raw or imper- 
fectly cooked food, often in the form of sausage. The trichinae are en- 



780 



SPECIAL DIAGNOSIS. 



cysted when absorbed, but within forty-eight hours they are liberated in 
the intestine and can be found adherent to the raucous membrane. In the 
course of six or seven days, each liberated female worm produces about 
180 embryos, which immediately penetrate the walls of the intestine and 
travel or are carried to all parts of the body, becoming in turn encysted. 

Swallowing of trichinous flesh does not necessarily produce symptoms; 
the trichinae may be destroyed in the stomach, or, if calcified, may pass 
through the intestine unchanged. When symptoms result, they depend 
upon the number of trichinae which become liberated. The symptoms 
produced are sleeplessness, lassitude, anorexia, nausea, vomiting, tender- 
ness over the abdomen, and diarrhoea. The symptoms may be so severe 
as to cause death in two or three days. If the patient survive, toward 
the end of the week the voluntary muscles become stiff, painful, and 
contracted. The muscles feel hard and swollen. The eyelids, face, and 
sometimes the feet become cedematous. Depending upon the muscles 
involved, there are interferences with the eye movements, contractions 
of the jaw muscles, difficulty in breathing or in swallowing, etc. The 
calves of the legs are especially involved. Recurrent oedema over the 
affected muscles, eyelids, and face, is very common and characteristic. 
Profuse sweating also is very common, and at times there are severe 
neuralgic pains. 

The fever is usually moderate, but it may be high. The pulse is 
very frequent if trichinae reach the heart. The later stages in fatal 
cases are marked by insomnia, delirium, stupor, and coma. 

The duration varies from a few days to four or five weeks or even 
longer. Muscular pains may persist for months after recovery. Death 
results from exhaustion, or from some complication, as pneumonia or 
ulceration of the large intestine. 

Diagnosis. It is distinguished from typhoid fever by the preseuce 
of vomiting and oedema of the face and eyelids, the development of 
muscular troubles, by the absence of hebetude, delirium, and other 
typhoid symptoms, and of the characteristic eruption and enlargement 
of the spleen. 

Muscular rheumatism is distinguished by being limited to one part, 
as the lumbar region, arm, or chest; by its appearance following ex- 
posure to a draught ; and by the fact that it is not preceded by nausea, 
vomiting, and diarrhoea, nor accompanied with oedema. 

Constitutional Syphilis. 

Constitutional syphilis may be acquired or congenital. 

Acquired syphilis is characterized, first, by the initial lesion, or 
chancre, which appears usually in a week after contagion ; second, by a 
period of incubation generally lasting six weeks, but varying from one 
to three months ; third, by so-called secondary symptoms, comprising 
febrile symptoms, polymorphous skin eruptions, ulcers upon the ton- 
sils, adenitis, less frequently mucous patches in the mouth, or condylo- 
mata about the anus, iritis and retinitis, and loss of hair. The lesions 
of this period are symmetrical. Fourth, after an interval varying 
from several months to twenty years, by so-called tertiary phenomena, 



THE INFECTIOUS DISEASES. 



781 



which manifest themselves in some cases. These are due to chronic 
inflammatory indurations of the skin and subcutaneous tissue, resulting 
in suppuration aud ulceration ; or of the bones, producing periostitis 
and necrosis ; or of organs, producing gummata and cirrhosis j or of 
the nervous system, resulting in gummata or chronic degenerative 
changes. The lesions of this period are un symmetrical. 1 

The course of syphilis in different persons varies as widely as with 
any of the eruptive fevers. In some the chancre is a mere papule which 
heals almost unnoticed ; no secondary symptoms appear, and tertiary 
symptoms also are altogether wanting, or a chronic degeneration of the 
nervous system develops after the lapse of many years, the patient in 
the meantime remaining in apparent health. All this may occur, too, 
without the aid of specific treatment. In other cases the disease is 
malignant ; tertiary symptoms appear very early or appear to take the 
place of secondary symptoms ; ulceration may rapidly melt down and 
destroy the alse of the nose or the soft palate ; or rebellious periostitis 
with necrosis may attack the tibiae, the nasal bones, or the cranium. 

In an ordinary case of acquired syphilis, in about six weeks after the 
appearance of the chancre the patient complains of languor, weariness, 
slight fever, pains in the bones, impaired digestion, and a tendency to 
anaemia, An eruption now appears. It is most marked on the trunk 
and upper extremities, especially the chest and forehead (corona Veneris). 
The eruption may be roseolous, squamous, vesico-papular, papular, pus- 
tular, bullous, or tubercular. The color has been aptly compared to 
that of a slice of raw ham. The enlargement of the inguinal, epi troch- 
lear, and post-cervical glands, which precedes the eruption, persists. 
Shallow ulcers with a sharply-defined grayish outline appear on both 
tonsils. They are painless and do not spread. Ulcers are also liable 
to appear upon the pharynx, buccal surfaces, tongue, angles of the mouth, 
penis, vulva, vagina, and around the anus. In the mouth these are 
apt to be very painful, and may persist in spite of treatment for weeks 
or months. Relapses are not uncommon. Sometimes there are raised 
white patches upon the pharynx. Sometimes the hair becomes very 
thin and falls out, leaving the patient without eyebrows and more or 
less bald. Iritis aud retinitis are usually later symptoms. Other 
symptoms occasionally occurring at this stage are periostitis, usually 
slight, and onychia. 

The most common of the symptoms enumerated are the eruption and 
the tonsillar ulceration. 

The eruption comes out gradually during two or three weeks and 
persists for about two months. Rarely, however, it is fleeting, or, on 
the other hand, is unduly prolonged. 

The secondary symptoms last from six to eighteen months. After 
their disappearance the patient may remain entirely well for life. In 
other cases after apparent health, lasting for months or years, the tertiary 
phenomena already mentioned appear. In the interval the patient may 
have suffered with various local skin eruptions or with ulcers upon the 
buccal mucous membrane. 



1 Fever is a constant accompaniment of all forms of syphilis. (See Fever.) 



782 



SPECIAL DIAGNOSIS. 



For a description of the tertiary lesions of syphilis see works upon 
surgery, and other articles in this book upon visceral diseases in the 
causation of which syphilis is a factor. 

Hereditary syphilis differs in some respects from the acquired form. 
At birth the syphilitic infant usually exhibits no evidence of its 
inherited taint. In the course of from one to twelve weeks it develops 
a catarrhal inflammation of the nasal mucous membrane, which causes 
snuffling in breathing, and hence is called " snuffles." An eruption soon 
appears, symmetrical in distribution. It is most frequently erythematous 
or papular, but it may be squamous, vesicular, pustular, or bullous. It 
is more apt to be moist and to favor the genitalia and flexures of the 
thigh than in acquired syphilis. It is of the same ham-color as in 
acquired syphilis. Coincident with the " snuffles " and eruption appear 
stomatitis and ulcers at the angles of the mouth, and sometimes con- 
dylomata around the anus. Meantime the child has begun to waste, to 
be peevish, to be anaemic, and gradually to assume the appearance of a 
wizened, dried-up old man. As in acquired syphilis, there may be 
iritis, though it is uncommon, and inflammation of the other structures 
of the eye, but nodes and disease of the liver are rare. The infant very 
frequently dies during this period from exhaustion and inanition. 

If the child survive for a year, the secondary symptoms usually dis- 
appear and the disease becomes latent. Relapses may occur, and in 
them, according to Mr. Hutchinson, condylomata are liable to appear. 
The same observer states that the tertiary period may begin at any time 
after the fifth year, but it is commonly delayed till about the period of 
puberty. In the meantime the patient may appear fairly well, but 
usually his development is retarded, there is a tendency to ansemia, and 
he has often naso-pharyngeal catarrh, flattening of the bridge of the 
nose, premature decay of the upper incisor teeth, and ' protuberant 
forehead. 

The teeth may be perfectly normal, in other cases characteristically 
syphilitic. The malformation affects especially the upper central 
incisors of the permanent set. It was first described by Mr. Hutchinson. 
It " consists in a dwarfing of the tooth, which is usually both narrow 
and short, and in the atrophy of its middle lobe. This atrophy leaves 
a single broad notch (vertical) in the edge of the tooth, and sometimes 
from this notch a shallow furrow passes upward in both anterior and 
posterior surfaces nearly to the gum. This notching is usually sym- 
metrical. It may vary much in degree in different cases ; sometimes 
the teeth diverge, and at others they slant toward each other." (See 
Fig. 75.) 

Further, the patient may have had or may now be attacked with 
keratitis, affecting both eyes, producing cloudy opacities and being 
accompanied by great photophobia. Again, there may be nodes upon 
the long bones, with nocturnal exacerbations of pain. Cerebral deaf- 
ness, according to Hutchinson, is not rare, but cerebral blindness is. 
There may be ulceration upon the legs, and periostitis and necrosis. 
The patient usually recovers completely, but he is more liable to be 
carried off by intercurrent disease than a healthy person, and in general 
has less resisting power, especially to tuberculosis. 



THE INFECTIOUS DISEASES. 



783 



Tuberculosis. 

Tuberculosis is an infectious disease, the course of which may be 
acute or chronic. It is caused by the bacillus tuberculosis. This micro- 
organism sets up a specific inflammation characterized by the develop- 
ment of nodules or tubercles, or by a diffuse growth of tuberculous 
tissue. Either anatomical product may undergo caseation or sclerosis, 
and in either instance, ulceration or calcareous degeneration. 

Invasion of the body by the micro-organism may give rise to general 
infection, with an eruption of miliary tubercles in most of the organs 
and structures of the body, or to a local infection. General tuberculosis 
is acute ; local tuberculosis may be acute or chronic. In acute tubercu- 
losis the serous membranes, the lungs, liver, kidneys, lymphatic glands 
and spleen, the bone marrow and the choroid coat of the eye may be 
invaded in whole or in part. In chronic tuberculosis the lymph glands, 
the lungs, the serous membranes, the tissues and organs of the aliment- 
ary canal, the liver, the organs of the genito-urinary system, and the 
brain and cord are individually invaded. 

The diagnosis of any form of tuberculosis is aided by the determina- 
tion of the chief factors in its etiology, where this is possible. First. 
The discovery of the bacillus tuberculosis in any inflammatory area, or 
any product of inflammation, as serum, blood, pus, or the secretion 
from any gland or mucous membrane invaded by the disease, establishes 
at once the diagnosis of this condition. The method of determining the 
presence of this micro-organism is fully detailed in the various descrip- 
tions of tuberculosis in the discussion of local diseases, and in the 
accounts of the examination of the sputum and of exudations and trans- 
udations. Second. As tuberculosis is an infectious disease, discovery of 
the infection is an aid in the diagnosis. Infection takes place by means 
of the inhalation of the sputum or other secretions, which when dry float 
about in the air. It implies in a measure more or less contact with 
individuals previously infected. In rare cases such contact is pro- 
ductive of the disease by means of direct contagion. The second source 
of infection is the food supply. This may occur from the consumption 
of milk secured from a cow infected with tuberculosis. The eating of 
meat of tuberculous animals may possibly lead to infection. Direct 
inoculation is another but rarer source of infection. This usually occurs 
accidentally only. Finally, it is possible that tuberculosis may be in- 
herited. A more prominent ^etiological factor, which aids in the diagnosis 
of the disease is the presence of a certain type of structure which is a 
marked hereditary characteristic in families, on account of which feeble 
resistance is offered to the invasion of the tubercle bacillus. The 
phthisical or phthisinoid chest which belongs to this type has been 
described elsewhere, and the tuberculous and scrofulous states out- 
lined (see pages 55 and 234). These anatomical conditions, which are 
inherited, undoubtedly favor the development of tuberculosis. 

It is a mistake to lay much stress in the diagnosis of tuberculosis 
upon the age or the occupation of the individual. Tuberculosis may 
occur at auy age. It is true, however, that at certain periods of life 
the tubercles are distributed more commonly in one group of organs, 



784 



SPECIAL DIAGNOSIS. 



while in other periods it affects another group. Lymphatic, joint, and 
meningeal tuberculosis is most common in the first decade of life. The 
mesenteric glauds are particularly open to invasion at this period. 

The diagnosis of tuberculosis, whether local or general, is further 
aided by a complete knowledge of the phenomena that attend the 
entrance of the virus into the body and the mode of diffusion through- 
out the body after infection has taken place. The phenomena at the 
point of entrance of the micro-organism are nearly always distinct. 
The general invasion is associated with symptoms like those of specific 
fevers. The local secondary effects upon the tissues are always decided. 
It must be borne in mind that after the exposure, which may lead to infec- 
tion, either an acute form of tuberculosis of a general character may be 
set up, with or without marked local symptoms, or acute local tubercu- 
losis may arise. In local tuberculosis the disease is confined to one 
organ or to the lymphatic glands and the organs in the lymphatic dis- 
tribution, as the bronchial glands, which are primarily affected, and the 
lungs. In these structures the entire process of nodular formation, 
caseation or sclerosis, ulceration or calcification, may take place. The 
disease remains primarily local. On the other hand, it may spread by 
continuity of structure through the lymphatics throughout the remainder 
of the organ affected, leading to its ultimate destruction and the death 
of the patient ; or general infection of the system may take place from 
the primary local area. The primary seat of infection may be the lungs, 
the larynx, or the alimentary tract of the genito-urinary organs. Primary 
tuberculosis of the serous membranes, of the lymph glands, of the 
bones and joints, may take place. 

The symptomatology and diagnosis of the various forms of tubercu- 
losis are detailed in the section devoted to the special diseases of the 
various organs of the body. 

Acute miliary tuberculosis has been spoken of elsewhere (see page 
317). Its course may resemble typhoid fever, septicaemia, or malignant 
endocarditis. It usually develops in the course of tuberculosis in some 
other organ of the body. The typhoid form has been described in the 
section indicated. It must not be forgotten that the diagnosis is ren- 
dered positive by the demonstration of the presence of tubercle bacilli 
in the blood, or of the occurrence of choroidal tubercles in the eye- 
ground. Another form is attended by marked pulmonary symptoms. 
This is the type seen in the bronchial pneumonia that occurs in children 
following measles and whooping-cough (see Catarrhal Pneumonia). 
Of the pulmonary symptoms dyspnoea is the most prominent. Cyanosis 
is marked. The physical signs are not prominent, and may be those of 
bronchitis alone. Although there is impaired resonance at the base of 
the lungs, areas of hyper-resonance are observed above and in front of 
the chest. Collapse of the lung may cause tubular breathing. The 
temperature rises to 102° to 103°. An inverse type may be seen. 

The diagnosis of acute tuberculosis is determined by the history of 
infection from extraneous sources or from local tuberculosis in some 
portion of the body, and the presence of bacilli. 

The following conditions should point to chronic tuberculosis in 
some portion of the body : 1, emaciation, not otherwise explained ; 2, 



THE INFECTIOUS DISEASES. 



785 



ansemia ; 3, weakness without cause ; 4, fever — the temperature should 
be taken every two hours night and day ; 5, causeless sweats ; 6, gastro- 
intestinal catarrh ; 7, morning nausea ; 8, signs of local inflammation 
in some organ of the body. 

Remarks on the Diagnosis of Infectious Diseases. 

A satisfactory diagnosis is only made when a correct appreciation of 
the evolution of the disease and facts concerning its activity are ascer- 
tained. The eruptive fevers, particularly, are differentiated with diffi- 
culty unless the chronological sequence of the phenomena of the develop- 
ment of the disease are weighed. These facts, in a suspected case, 
relate to the history of exposure of the patient, the presence of an 
epidemic, the presence of conditions favorable to the development of 
the disease, etc. The following should be ascertained : 

1. The occurrence of an epidemic. In a suspected case it may be of 
weight in aiding in the distinction of the disease. 

2. The history of exposure to the suspected infection, either mediate 
or immediate, remotely in time or place, must have great value. 

3. Immunity, acquired or artificial, to a particular disease, may ex- 
clude that affection. The eruptive fevers rarely occur a second time. 
One attack of erysipelas, however, predisposes to subsequent attacks. 

4. Etiological facts pertaining to the suspected disease, as hygienic 
surroundings, a malarial region, etc. Other factors bearing on aetiology, 
as the season in cases of typhoid fever, are often valuable in pointing to 
the affection. 

5. The Age. The eruptive fevers are peculiar to childhood, typhoid 
fever to early adult life. 

6. The occupation in affections transmitted from animals to man. 

7. The duration of incubation, the mode of onset, the mode of 
development, the characters of specific features, and the day of the 
development of each, are important data to aid the diagnosis. 

Simple Continued Fever. 

A non-contagious fever, lasting from one to twelve days, not depend- 
ing upon any known specific cause and not attended with definite local 
lesions. Its chief characteristic is the continued elevation of temperature. 

It occurs especially in children and in those prone to a ready disturb- 
ance of the heat-regulating apparatus. Great mental and physical 
exhaustion, prolonged bathing in the hot sun, and disturbances in clges- 
tion may cause it. Perhaps, as suggested by Guiteras, some of the cases 
occurring in the tropics and in very hot weather should be regarded as 
very mild forms of thermic fever. 

The onset of the disease is abrupt. There may be a chill, or in 
nervous children a convulsion ; but these are rare. The temperature 
rises rapidly to 102°-104°, accompanied with headache, thirst, rest- 
lessness or drowsiness, loss of appetite, a coated tongue, constipation, 
and occasionally nausea. The urine is scanty and sometimes there is a 
heavy deposit of urates. There may also be more or less muscular 

50 



786 



SPECIAL DIAGNOSIS. 



soreness. Sometimes within twenty-four or forty-eight hours there is 
free perspiration and a rapid subsidence of the fever and all its symp- 
toms. This is ephemeral fever. 

In other cases the fever continues for a week or ten days longer. 
Daring this time the symptoms already noted continue. Sleep is 
disturbed and mild delirium is at times present. Eespiration and 
pulse are not much accelerated. Sudamina upon the abdomen and 



Fig. 148. 







£ 




E 


M 


E 




E 




E 




E 


M 


E 


M 


E 




E 




E 










































































































































































o- 










































I02- 
























i 


























































































































| 
































































IOI- 




































































































i 
































































IOO- 




























































































I 














1 


















































































































































99- 










































































ft 
















i 
























































































































98- 












































































a 


































f 


























































0- 










































97- 


















































































































































































































Date 


1 ^10 


12 


13 


14 


15 


16 




18 


10 


20 



Simple continued fever. 



herpes upon the lips are common. Pale-bluish macular are sometimes 
seen. The spleen is not enlarged except in very rare cases, and there 
are no local evidences of disease. The fever subsides more gradually 
than in ephemeral fever, the defervescence being marked at times by 
perspiration, a few loose stools, a copious deposit of urates in the urine, 
or by hemorrhages from the nose, rectum, uterus, or urethra. 

The diagnosis from other fevers aud febrile affections is made by the 
absence of any characteristic eruption, of enlargement of the spleen and 
liver, and of any lesion, such as endocarditis, bronchitis, or pneumonia. 



CHAPTEE XI. 



DISEASES OF THE NERVOUS SYSTEM. 

Disturbances of sensibility, disturbances of motility, ataxia, dis- 
turbances of the reflexes, vasomotor and trophic disturbances, and dis- 
turbances of intellection are produced by diseases of the nervous system. 

The Disturbances of Sensibility. 

In anaesthesia there is diminution or absence of sensibility. In hyper- 
esthesia the sensibility is abnormally increased, so that even weak 
irritations may produce painful sensations. Parcesthesia are abnormal 
sensations in the skin, as formication, numbness, pricking, etc., which 
are also called symptoms of sensory irritation. Actual pain may also 
be one of the symptoms of sensory irritatiou. Such abnormal sensations 
are due to morbid states of the nerve itself. 

Cutaneous sensibility is of several varieties, and hence to determine 
any change the various forms of sensation must be tested. In nervous 
diseases one variety of sensation may be destroyed while other sensations 
remain intact. Such abnormal chauges are known as partial anaesthesia? 
or paralyses of sensation. The following varieties of cutaneous sensi- 
bility are investigated : 

1. Tactile Sensibility. Tactile sensibility is tested by touching the 
skin with the finger or a blunt object. The patient's eyes being closed, 
he is asked whether he has perceived the touch or not. It is well some- 
times to control the experiment by asking the question without making 
contact with the skin. Comparative test should be made of the 
opposite side, which is presumably healthy. By the tactile sense the 
form of objects aud the external characters are also judged. Smooth, 
rough, hard, soft, round, or angular objects are employed. The eyes 
must be kept shut. Familiar objects may be used ; when placed in the 
hand the patient is made to name them if possible. Coins, keys, or 
wooden geometrical objects are used for this purpose. 

2. Sense of Locality. When any part of the surface of the body is 
touched we can, under normal conditions, tell the exact locality of the 
point of contact. This ability to localize the sensation is lost by patieuts 
with nervous diseases. lu addition to designating directly, or by means 
of the hand, the part of the body that is touched, the tactile sense is also 
tested by means of compasses. By this method the patient is subjected 
to two simultaneous irritations of the skin at the same time. The 
points of the compass may be distinguished as separate irritants at from 
11 to 15 mm. on the cheeks, 6 mm. at the tip of the nose, 1.2 mm. at 
the tip of the tongue, etc. At the tips of the fingers the two points 
can be detected at from 2 to 3 mm. ; on the thigh, 77 mm. Various 



788 



SPECIAL DIAGNOSIS. 



modifications of this test must be employed to control the results, as by 
bringing down one point at a time, or at a different place each time. 

3. Sense of Pressure. This sense is tested by placing the hand 
on a firm, hard surface like a table, and placing graduated weights 
upon it. Change in this sense may be confirmed by employing pressure 
with the hand or a pencil upon the skin, using various degrees of force. 

4. Sense of Temperature. Thermic sensibility is tested by the appli- 
cation of hot and cooler bodies alternately. The sensations to heat 
and to cold are due to distinct functions, and therefore may be separ- 
ately modified. The heat sense may be abnormal, while the cold sense 
is often unchanged. The application of either hot or cold objects, if the 
sense of temperature is impaired, may not be perceived at all. The 
sense may be blunted, so that hot water feels as if it was simply tepid, 
or it may be lost entirely, the patient perceiving the touch, but not the 
temperature of the object applied. In partial anaesthesia to cold the 
application of a bit of ice may be described as causing a warm sensation. 
Differences of temperature are recognized by these functions. In health 
a difference of one degree Fahr. in the temperature of the body is usually 
distinguished without difficulty. The face and fingers are even more 
sensitive. The difference in temperature may be determined by applying 
vials filled with water at varying temperatures. 

5. Sensation of Pain. Loss of sense of touch does not necessarily 
imply loss of sensation of pain. The former may be lost, while pain is 
readily excited in the affected area. The loss of sensibility to pain is 
know T n as analgesia. It is of common occurrence in peripheral and 
central nervous diseases. The point of a pin, thermal irritants, elec- 
trical currents, or pinching of the skin, are methods used to determine 
the sensation of pain. 

6. Electro-cutaneous Sensibility. This is determined by faradization, 
but does not give any better information than is secured by testing the 
tactile sense and the pain sense. 

7. Delayed Conduction of Sensation. After the irritant is directly 
applied in certain diseases the patient does not respond for a considerable 
interval of time. This delay of conduction is seen in locomotor ataxia 
particularly. The sensation of touch may be perceived several seconds 
before the sensation of pain. 

8. The Muscular Sense. By the muscular sense we are enabled with- 
out the sense of sight to tell the position of our limbs. After any 
passive movements made by an observer a healthy person can tell at 
once the direction and character of the movements. In patients with 
nervous diseases this faculty may be lost. When a patient is called 
upon to make a definite movement, the eyes being closed, this movement 
is not completed, or is incorrectly made, if the muscular sense be lost. 

Ancesthesia of the Skin. Any break in the conducting path from the 
surface of the body to the centres of sensation in the cerebral cortex 
causes anaesthesia, which may be complete or partial. Anaesthesia may 
be peripheral, spinal, or cerebral. In peripheral ancesthesia the termina- 
tions of the sensory cutaneous nerves do not respond to irritations. 
This is seen after the application of anaesthetics to the skin, or of cor- 
rosive substances, as acids or alkalies, carbolic acid, etc., or from the 



DISEASES OF THE NERVOUS SYSTEM. 



789 



use of cocaine or morphia. Another form of peripheral anaesthesia is 
due to disease, of the uerve trunks from trauma, from compression of 
the nerve, or from neuritis. 

Spinal Ancesthesia is seen in disease of the spinal cord, particularly 
when the posterior roots, the posterior columns, and the posterior cornua 
are diseased, as in locomotor ataxia. It is also seen in acute and 
chronic inflammation of the cord, and in compression or in new growths. 
The anaesthesia is bilateral. 

Cerebral Ancesthesia is seen in hemorrhages, local softening and 
tumors, which affect the posterior portion of the internal capsule. 
When half the body is affected it is known as hemianaesthesia, and is 
on the opposite side of the lesion. In hysteria anaesthesia is often seen. 

Neuralgia. 

Neuralgia is characterized by pain in the course or distribution of 
the affected nerve. The pain is of pronounced severity, and occurs in 
remissions and intermissions. The symptoms of a neuralgic paroxysm 
may be preceded by hyperaesthesia over the part subsequently affected. 
The pain is of a burning or shooting character. It is usually limited 
to the distribution of the affected nerve, or may extend into other 
regions. It may be excited by external irritants, by mental excitement, 
and often by movement of the part. On examination, the territory of 
the affected nerve may be anaesthetic. Usually, however, there is 
hyperaesthesia of the skin. Wherever the affected nerve is accessible to 
pressure pain can be elicited. The nerve-trunk may be tender during 
the attack, and during the intervals between the attacks. Often in 
neuralgia there is some spasm of the muscles supplied by the nerve. 

Vasomotor symptoms are common. The skin may be pale, or the 
area reddened. When the trigeminal nerve is affected the skin and 
conjunctivae are both reddened. The secretions, as the tears, may be 
modified. Eruptions like urticaria or herpes may develop along the 
course of the nerves. Prolonged neuralgia may cause marked nutritive 
disturbances. 

General Conditions. The patient who is the subject of neuralgia may 
be in apparent good health. The neuralgia may be due to constitutional 
causes, as rheumatism or gout ; to some form of toxaemia, as malaria ; 
to some condition of the blood, as anaemia; and may be due to trauma 
or cold. 

The following individual forms of neuralgia are seen : 1. Neuralgia 
of the trigeminus, or tic douloureux. The fifth pair in its entirety or 
some of its branches are affected. The pain may be associated with 
twitchings ; with vasomotor disturbances with eruptions, and with 
changes in the secretions. Trophic changes, as the hair turning gray, 
or atrophies, may follow. The first branch (ophthalmic) ; the second 
branch (supra-maxillary) ; the third branch (infra-maxillary), are most 
frequently affected. Points of pressure are usually readily detected at 
the foramina for the exit of the nerves. 2. Occipital neuralgia. 3. 
Neuralgia of the brachial plexus. 4. Intercostal neuralgia. 5. Neur- 
algia of the lumbar plexus, of which we have lumbo-abdominal, crural 



790 



SPECIAL DIAGNOSIS. 



aDd obturator neuralgia. This form of neuralgia (lumbar plexus) must 
not be confouucled with boue and joint disease; with lumbago; renal 
colic ; appendicitis, and uterine affections. 6. Sciatica. 7. Genital and 
rectal neuralgia. 

Trigeminal neuralgia must be distinguished from headache due to 
other causes, affections of the bones and periosteum, and affections of 
the teeth. The distribution of the pain ; the points of pressure ; the 
paroxysmal character of the pain, aid in the diagnosis. 

Disturbances of Motility. 

Paralysis is a loss of power of the muscles of the body controlled by 
the will. It must be distinguished from loss of motion or inhibition of 
function due to disease of the muscle, or to pain which is excited by 
movement. The presence of tenderness and of pain on passive motion 
serves to distinguish this form of paralysis. 

When there is absolute loss of power the paralysis is complete ; when 
there is weakness of the muscles, it is known as paresis. In this latter 
condition certain movements are possible. 

Causes. Disease in any portion of the cortico-muscular conduction- 
path or pyramidal tract may lead to paralysis. Destruction of the 
function of the motor centres in the cerebral cortex may lead to paraly- 
sis. Paralysis is also due to disease of the muscles. It is known as 
myopathic paralysis. 

Paralysis of one lateral half of the body is known as hemiplegia. 
One-half of the face, the arm and the leg, or an arm and a leg of one 
side alone are paralyzed. The trunkal muscles are not affected in hemi- 
plegia. Hemiplegia is invariably of brain origin. Paralysis of the lower 
transverse half of the body is known as paraplegia. It is of spinal 
origin. A monoplegia may be facial, brachial, or crural, according to 
the situation of the paralysis. Monoplegias are due to diseases of the 
brain, of the spinal cord, or of the nerve trunk. Monoplegia of 
cerebral origin is always cortical. Monoplegia of spinal origin is seated 
in the ganglion cells of the anterior cornua. A local -paralysis is loss 
of power of a single muscle or group of muscles. When many local 
palsies exist it is known as multiple paralysis, A local paralysis is 
frequently due to disease of the nerve trunk — a neuritis. 

The symptoms of paralysis are recognized by the patients' statements 
and by physical examination. 1. There is loss of power of the mus- 
cles. 2. Change in the character of the muscles. 3. Changes in the 
reflexes, the nutrition, and the sensations. Changes in the condition of 
the paralyzed muscle are valuable diagnostic criteria as to the cause of 
the paralysis (see page 135). 1. The paralyzed muscle may retain its 
normal volume and normal nutrition. 2. The muscle may be atrophied. 
To this class belong the atrophic paralyses. In the former instance the 
break in the ganglion of the motor fibres exists somewhere between the 
cortex and the cells in the anterior cornua. In atrophic paralyses the 
cause is seated in the ganglion cells or in the peripheral nerves. The gan- 
glion cells must influence the nutrition of muscles. If they are normal 
and the nerves not affected the nutrition of the muscles remains good. 



DISEASES OF THE NERVOUS SYSTEM. 



791 



In addition to the atrophy of the muscles, the nerves proceeding from 
the point of lesion to the muscle atrophies or degenerates. On account 
of this degeneration certain reactions are brought out by electricity 
(see Electrical Diagnosis). 

When passive motion is performed in some forms of paralysis there 
is resistance to the movements on account of contraction of the muscles. 
They are known as spastic paralyses. When muscular resistance is 
lessened they are known as flaccid paralyses. In long-continued paraly- 
sis contracture of the muscles takes place. It must not be confounded 
with spastic paralyses. 

In paralysis of the face the mouth is drawn toward the sound side, 
unless contractures take place in the paralyzed muscles. In paralysis 
of half the tongue when it is protruded the tip turns toward the para- 
lyzed side. 

Motor Irritation. Motor irritation is indicated by spasm, which 
is a morbid movement excited independently of the will. Spasm is due 
to irritation somewhere in the motor tracts. The irritation may act 
directly on the nerves or be produced by an irritation in the periphery, 
as in reflex spasms. 

Spasms may be clonic or tonic. When the muscular contraction lasts 
but a short time, and is followed by relaxation, the two alternating 
rapidly, they are clonic in character. There is constant convulsive 
movement. In tonic spasm there is persistent contraction of the 
muscle. Tonic and clonic spasms may alternate in the same indi- 
vidual, or the same group of muscles. 

Spasms are also divided into many forms, depending upon the degree 
and character of the motor irritation. They are all grouped under the 
head of motor irritations. 1. Epileptiform convulsions are clonic spasms, 
or tonic-clonic. They may extend over the whole body, or be limited 
to one-half the body, or to one portion, as the arm or leg. The true 
type is seen in epilepsy, in hysteria, and in organic disease of the brain. 
2. Rhythmical contractions. There is more or less continuous moderate 
contraction of groups of muscles. They are seen in apoplexy, in cerebral 
sclerosis. Such contractions occur before or after an epileptic fit. 3. 
Tremor. The spasms are moderate, rapidly succeeding one another, 
small in extent: when most severe, known as " shaking." Tremor 
is seen in paralysis agitans in its most pronounced form. We also have 
senile tremor, alcoholic tremor, hysterical tremor, and tremor due to 
metallic poisonings. It is also seen in exophthalmic goitre. Tremor 
without known cause is sometimes hereditary. 4. Sudden tioitchings, 
or a contraction of one or more muscles, may be due to direct motor 
irritation, or be of reflex origin in disease of the spinal cord. 5. Fibril- 
lary contractions are due to spasm of separate fasciculi of the muscles. 
Such contraction is seen is spinal progressive muscular atrophy. 6. 
Choreiform movements. The movement may be slight and local, or 
general. It may be confined to the face or to an extremity. The 
movements are usually interrupted by pauses of irregular length. They 
occur in chorea and after hemiplegias. 7. Athetosis. (See page 131.) 
Slow involuntary movements, chiefly of the arm and hand, occur. 
They are of common occurrence in the cerebral paralysis of children. 



792 



SPECIAL DIAGNOSIS. 



8. Coordinated spasms are forced complicated movements, as spasms 
of jumping, laughing, running, moving in a circle, or turning about 
the axis of the body. They may be associated with spasm of the respira- 
tory, pharyngeal, aud laryngeal muscles. They occur in hysteria, cer- 
tain forms of epilepsy, and disease of the cerebellum. 9. Tonic spasms. 
The muscles are in a constant state of rigidity, as the muscles of masti- 
cation in trismus. Muscles of the back and neck, when in tonic spasm, 
cause opisthotonos. 10. Catalepsy. The muscles remain in any posi- 
tion given to them on passive movement. They are deprived of the 
will. Catalepsy occurs in hysteria ; rarely in meningitis. 

Convulsions are divided into epileptiform or cerebral convulsions, in 
which consciousness is lost ; hysterical convulsions, in which, conscious- 
ness is disturbed, and spinal convulsions, in which consciousness 
is normal and reflex actions are exaggerated. 

Ataxia. In ataxia, or incoordination, there is want of simulta- 
neous action of muscles which are required to conduct complicated 
movements. Either there is (1) undue spasm, or (2) paralysis or pare- 
sis of one or more of the muscles involved in the complicated move- 
ment, or (3) the innervation of the muscles is abnormal, so that irregular 
contraction takes place in the production of the movement. The com- 
pletion of a complicated act, as walking, is known as coordination. 
When the muscles do not act simultaneously incoordination is pro- 
duced. Ataxia may involve all the muscles of the body or one of the 
extremities, so that we may have an ataxia of the arm, etc. Ataxia 
occurs in disease of the cerebellum and the spinal cord, as in loco- 
motor ataxia (see page 60). 

The Reflexes. 

The reflexes are of two kinds, cutaneous reflexes and tendon reflexes. 

Cutaneous Reflexes. When the sensory cutaneous nerves are irritated 
muscular contractions are excited in the vicinity. They are known as 
cutaneous reflexes. They are excited by pricking or pinching or by 
tickling the skin. The reflexes of the upper extremities are not marked. 
In the lower extremities they are more pronounced. They may be 
excited by tickling the soles of the feet, by pricking them with a pin, 
or by the application of ice to the skin. 

In nervous diseases there is often delay in the reflexes, that is, no 
response to the irritation occurs until ten or fifteen seconds elapse. The 
reflex contractions are usually confined to the irritated limb. The 
irritability may be so great, however, as to cause a response from both 
legs or even the whole body, as in tetanus or strychnia poisoning. The 
following are special forms of cutaneous reflex : The abdominal reflex ; 
the cremaster reflex (the scrotum is drawn up when the skin of the inside 
of the thigh is irritated) ; the gluteal reflex ; the mammillary reflex, etc. 

Even within the bounds of health variations in the reflexes occur in 
different individuals. If possible it is important to compare the 
reflexes on symmetrical portions of the body. 

Absence of cutaneous reflex is seen in disease of the peripheral nerves 
and of the spinal cord, because the conduction of the reflex is inter- 



DISEASES OF THE NERVOUS SYSTEM. 



793 



r opted in its course. They are also absent when the reflex centres lose 
their irritability. Increase of the cutaneous reflexes occurs in strychnia 
poisoning, in cutaneous hyperesthesia, and in general neuroses, because 
of increased irritability of the parts. In disease of the brain and spinal 
cord which causes degeneration of reflex centers or the inhibitory 
processes, they are abolished. 

Tendon Reflexes. Muscular contractions occur from irritation of the 
tendons, the periosteum, or the fasciae. The nerves of the tendon are 
irritated and excite reflex contraction. 

The patellar reflex. This is detected when the patient crosses the 
leg loosely over the opposite knee, or when the limb is held up and 
hangs over the arm in a relaxed state. The tendon of the quadriceps 
muscle is struck by the finger or pleximeter. All muscular tension of 
the leg must be avoided. The reflex may be exaggerated by simulta- 
neous muscular effort on the part of the patient, as contraction of a 
hand when the blow is given. 

Ankle clonus. When the tendo Achillis is made tense by a short, 
vigorous, dorsal extension of the foot the reflex is exaggerated, plantar 
flexion of the foot taking place. If persistent dorsal extension of the 
foot be applied the foot is put into a vigorous tremor. Other reflexes 
are obtained in the lower extremities. They are elicited by a blow on 
the periosteum or fascia?, etc. 

The tendon reflex is absent in poliomyelitis, locomotor ataxia, and 
peripheral neuritis. It is increased in cerebral and spinal paralysis. 

Vasomotor, Trophic, and Secretory Disturbances. 1. Vasomotor par- 
alysis. This is indicated by abnormal redness of the skin, with increase 
in the temperature and a sensation of heat. They occur in functional 
neuroses, as hysteria and neurasthenia, and follow injuries of the sym- 
pathetic nerve. (See Hyperemia, p. 172.) 

2. Vasomotor spasm. There is pallor and coolness of the skin, 
because of spasm of the small vessels. There is formication and stiff- 
ness. It is most common in the hands. It may give rise to trophic dis- 
turbances, as in symmetrical gangrene, scleroderma, and similar diseases. 

The following trophic disturbances described elsewhere are symp- 
toms of functional or organic disease : 1. Angio-neurotic cedema. 2. 
Herpes zoster. 3. Urticaria. 4. Atrophy of muscles and nerves. 5. 
Atrophy of the skin (see Glossy Fingers). 6. Acute bedsores. 7. 
Myxcedema. 8. Trophic changes in the skin, nails, and hair. 9. Acro- 
megalia. 10. Trophic swellings of the joints. 

Electrical Diagnosis. 

For purposes of diagnosis we use two forms of current — the faradic 
and the galvanic. Practically we study the reaction of the muscle to 
stimulation through its nerve, for we cannot, except in experimental 
work upon animals, in which nerve and muscle can be isolated, limit 
the action of the current to a muscle without influencing the nerve fibres 
in it. In testing a nerve it will be found that the result varies accord- 
ing to the current used. Thus, if the two poles of a faradic battery be 
applied, say, to the ulnar nerve, there results a muscular contraction, the 



794 



SPECIAL DIAGNOSIS. 



presence and force of which depends upon the strength of the current 
and not upon which pole is directly over the sensitive point. With the 
galvanic current the matter is more complicated. If one large electrode 
is placed at some indifferent point, say on the sternum or between the 
scapulae, and the other smaller electrode over the nerve, and the current 
passes, it will be found that so long as the current is not interrupted 
no contraction of the muscle will occur. If, however, the moderately 
strong current be interrupted there will appear at each opening and 
closing of it a contraction. But the presence of a contraction depends 
upon which pole is over the nerve and whether the current is opened 
or closed. That is, the strength of current needed to produce a con- 
traction varies according to whether the positive or negative pole is 
over the nerve and whether the current is opened or closed ; in other 
words, if we begin with a very weak current there is no contraction 
under any circumstances, and in slowly increasing it we find that the 
first contraction occurs when the negative pole is over the nerve and 
the current closed. At the moment of opening the current, and when 
it passes without interruption, there is no contraction. If the current 
is increased still more, the contraction at closing — the negative pole still 
being over the nerve — becomes stronger, and as the current is increased 
contraction will occur when the positive pole is over the nerve. In 
this case contraction usually appears first at the opening and later at the 
closing. If the current be still further increased we obtain a contrac- 
tion at the opening, the negative pole being over the nerve. In order 
to obtain this reaction the current may need to be so strong as to be 
painful. This, then, is the order in which contractions occur in the 
healthy nerve and muscle. We can make it more easily understood by 
the following formula. Let A. represent the positive pole or anode, C. 
the negative pole or cathode, O. the opening, and C. the closing. Thus : 

Negative closing = C. C. 
Positive opening = A. 0. 
Positive closing = A. C. 
Negative opening = C. O. 

Any deviation from this formula denotes disease. For instance, if 
C. O. contraction occurs with the same strength of current as C. C. 
contraction it would be conclusive evidence of some pathological change 
in the nerve or trophic centres. In certain diseases we find distinct and 
definite changes in their reactions. Let us take, for instance, the peroneal 
nerve in a case of acute anterior poliomyelitis. For the first few days 
after the onset of the disease there will be a diminishing response of the 
nerve to both faradic and galvanic currents. If the current be applied 
directly over the muscle it will be found that the response to faradism 
rapidly decreases and finally may be entirely lost, while the response to 
galvanism is not nearly so much diminished, and may, toward the end 
of the second week, actually increase. Not only do we have an in- 
crease but the polar reaction is changed, so that A. C. contraction 
may equal C. C. contraction, and after a while C. O. contraction may 
equal A. O. contraction, or CO. contraction may appear witli a less 
current than A. O. contraction. The character of the contractions varies 
also. In the healthy muscle they are quick, shock-like ; in the diseased, 



DISEASES OF THE NERVOUS SYSTEM. 



795 



sluggish and worm-like. These alterations constitute the reaction of 
degeneration (De. R.). Finally, the muscle may cease to respond to the 
galvanic current no matter how strong it may be. 

The reaction of degeneration often requires much skill to determine, 
and as it is probably never present in a muscle which contracts normally 
to the faradic current the failure of response to this current is the best 
test for the practitioner as to the condition of the muscle and nerve. 
The presence of reaction of degeneration meaus that the lesion is either 
in the nerve trunk (neuritis), the anterior motor cells of the cord (polio- 
myelitis), or the nuclear origin of a nerve. It is never caused by a 
cerebral lesion. In purely muscular diseases, as, for example, pseudo- 
muscular hypertrophy, there may be diminution or absence of electrical 
response but never reaction of degeneration. 

Cerebral and Spinal Localization. 

Since the discovery by Broca, in 1861, that certain disturbances of 
speech are associated with lesions of the third left frontal convolution, 
and the discovery by Fritsch and Hitzig, in 1870, that irritation of 
certain areas of the cortex of the brain produces movements in definite 
groups of muscles, investigation has shown that definite areas of the 
cortex are concerned with definite functions. Some of these areas 
(centres) are now w T ell known and their localization determined, and it 
is the purpose of the present chapter to study the symptoms found in 
diseases of them. The position of a lesion, then, is determined by the 
symptoms; but all symptoms are not of equal localizing value, some 
indeed being valueless. All symptoms are due either to destruction or 
irritation of nerve tissue, and both occur in every lesion. The former, 
called " direct," are permanent unless some other part assumes the 
function of the part destroyed. The latter, called "indirect," are transi- 
tory unless the lesion be a slowly increasing one, in which case, as for 
example a tumor, they recur but do not persist. "Indirect" symptoms 
are produced by changes in circulation and compression around the 
focus of disease. We must wait for them to pass away before attempt- 
ing to localize the lesion. Again symptoms are "focal" or "diffuse." 
The former are due to interference with the function of some definite 
part of the brain, while the latter may be caused by disease in any 
position. The commonest "diffuse" symptoms are headache, vomiting, 
loss of consciousness, and optic neuritis. The value of "focal" symp- 
toms in localization depends upon whether they occur only when the 
lesion is in one definite area or in one of several. If the onset is acute 
it is necessary to know that all the symptoms appeared at the same time, 
as otherwise they must have been caused by different lesions. In a 
chronic but progressive disease there is, of course, gradual increase of 
the symptoms. 

Cerebral Localization. 

Cerebral Cortex. The motor area includes the ascending frontal, the 
parietal, and the posterior portion of the frontal convolutions and the 
paracentral lobule. The upper third contains the centre for the leg of 



796 



SPECIAL DIAGNOSIS. 



the opposite side, the middle third that for the arm, and the lower third 
that for the head and neck. The centre for the motor mechanism of 
speech is in the third left frontal convolution. 



Fig. 149. 

PRAECENTRAL F. ,F.R0LAN0O 



PARIETAL F. 



1%*- N FR0NTAL 




PARtETO-OCClPlTAL K 



229 FRONTAL F ' 



16J- TEMPORAL F. 21 d . TEMPORAL F. 

Convolutions ol the left hemisphere. (L. C. Gray.) 



Destructive lesions in this area cause paralysis of one limb (mono- 
plegia), or of a group of muscles. In order that all the centres should 
be affected and palsy of the opposite half of the body (hemiplegia) ensue, 
the lesion would have to be so great as, in an acute disease, to cause 



Fig. 150. 




Diagram showing localization of centres in the cortex. (L. C. Gray.) 



immediate death. If, however, the lesion is not confined to the gray 
substance but penetrates the white matter, fibres from healthy portions of 
the cortex may be interrupted and a more extensive palsy result than is 
found in a purely cortical lesion. Further, a minute lesion of the 
white matter may, as shown below, produce a monoplegia, aud there- 



DISEASES OF THE NEKVOUS SYSTEM. 797 

fore, palsy of one extremity does not prove absolutely the presence of 
cortical disease. 

Irritative lesions cause convulsion in the muscles controlled by the 
affected part. The convulsions, however, are often not limited to the mus- 
cles in which they arise, but extend throughout one side or over the whole 
body. Again, while several centres may be diseased, the convulsion 
may always start in one limb or group of muscles. In general, we 
may say that convulsion is of less localizing value than paralysis, be- 
cause in the latter case the seat of disease must be in the centre itself, or 
in the fibres from it, while in the former it need only be near the 
centre. General convulsions are of course of no localizing value. 

Pre-frontal Lobe. Lesions of the frontallo be anterior to the motor 
area produce either no symptoms at all or purely mental ones, and hence 
it was formerly held that this area was the seat of the mind. It is now 
largely held, however, that mind is an attribute of the entire cerebral 
cortex, and it is certainly true that lesion in any part may, if extensive 
enough, produce mental symptoms. 

Cortical Centres of Speech [Aphasia). The speech centres are situated 
in the third left frontal and first temporal convolutions in right-handed 



Fig. 151. 




Wernicke's schema for the cortical mechanism of speech. 



people, while curiously enough in left-handed people the centres are 
usually if not always upon the right side. Lesion of them or of the 
association path between them situated in the insula (?) results in different 
forms of affection of speech called collectively aphasia. It must be 
remembered that aphasia is not due to a paralysis of the muscles of 
articulation and phonation, but to a mental inability to select the proper 
word or to determine the necessary movements for its pronunciation. 

In the accompanying diagram from Wernicke the motor (y) and 
sensory (x) speech centres are represented. If the lesion is at y f motor 
aphasia results. There is no palsy of the muscles used in speech, and 
the patient hears perfectly and knows what he wishes to say, that is, he 
has perfect recollection of words, yet he cannot speak at all or can only 
say a few words or syllables. There is often inability to write (agraphia) 
without paralysis of the hand or mind-blindness, and sometimes inability 
to read (alexia). 



798 



SPECIAL DIAGNOSIS. 



If the lesion is at x, which is the termination of the centripetal path 
of the auditory nerve, "sensory aphasia," " word-deafness," results. 
The power of hearing sound is preserved, but the ability to interpret the 
meaning of heard words is lost. If the lesion is absolute the patient is 
unable to repeat heard words. He may have as large a vocabulary as 
ever, but he makes mistakes both in the words used and in their form. 
The errors are especially marked in the voluntary revival of words, 
while automatic speech, as in singing or swearing, may be normal. 
Nouns are more apt to be lost than verbs, adjectives, and prepositions. 
Circumlocution is often used — for example, the patient may say " that 
with which one cuts," meaning " knife." 

If the lesion is between y aud x in the insula (?), "amnesic" or "con- 
duction aphasia," results. In this case there is no loss in the motor 
speech processes nor word-deafness, but there is difficulty in recalling 
words, and they are used improperly. If both x and y be involved 
there is " total aphasia." The patient loses both power and under- 
standing of speech. 

Fig. 52. 




Schema illustrating the seven different forms of aphasia, a A, centripetal path for auditory 
impressions ; A, centre for auditory images ; M, centre for motor images ; Mm, centrifugal motor 
path ; B, the place where concepts are formed ; 0, the centre for visual images ; E, the centre from 
which the organs of writing are innervated. (Lichtheim.) 



If the lesion is in the supra- marginal and angular convolutions, 
"alexia," "word-blindness," results. The patient cannot recall the 
appearances of words and does not recognize print or writing. He may 
be able to pronounce letters and can often write correctly, but cannot 
read understandingly what he has written. Word-blindness is a part 
of the larger symptom "apraxia," mind-blindness, in which the patient, 
while seeing objects, fails to recognize their nature and characteristics by 
vision. 

A study of the above diagram from Lichtheim will probably make 
the whole subject clearer. 

In apraxia the concept centre (B) is affected ; in motor aphasia the 



DISEASES OF THE NERVOUS SYSTEM. 



799 



lesion is at m ; in sensory aphasia the lesion is at A ; in alexia 
the lesion is at 0 ; in conduction aphasia the lesion is somewhere in the 
path connecting A M and 0 M. In every case of suspected aphasia 
the following tests should be made : 1. Ability to recognize the nature 
and uses of objects. 2. Ability to recall the names of things seen, 
smelled, tasted, touched, or heard. 3. Ability to understand spoken 
words. 4. Ability to understand printed or written words. 5. Ability 
to understand musical tunes. 6. Power of voluntary speech. 7. Ability 
to read aloud and understand what he reads. 8. Ability to write and 
understand what he has written. 9. Ability to copy writing or print. 
10. Ability to write at dictation. 11. Ability to repeat words heard. 

It must be remembered that by the bedside the problem is much 
more complex than appears here. The cases are often not clearly 
separated, but various types run into each other, and the severity of the 
symptoms varies greatly. 

Fig. 153. 




Convolutions of the vertex, on the right ; on the left, the basal ganglia, internal capsule, 
centrum ovale, and the cuneus. (L. C Gray.) 

Parietal Lobe. Extensive disease probably interferes with sensation 
on the opposite side of the body. The functions of the ascending 
parietal and of the paracentral lobules have already been described. 

Occipital Lobe. The cortical centre of vision is in the cuneus and the 
adjacent convolutions. Disease in it produces hemianopsia which is 
described under a special heading. 

Corpus Callosum. No localizing symptoms occur in disease in this 
region. Mental dulness and bilateral weakness result sometimes from 
tumor. The centrum ovale contains fibres from the cortex which come 
closer together and occupy a smaller and smaller space until the internal 



800 



SPECIAL DIAGNOSIS. 



capsule is reached. It follows, therefore, that the nature of the syrnp- 
toms will vary with the distance of the lesion from the cortex. If near 
the cortex the symptoms must resemble those found in corresponding 
cortical disease, while if near the internal capsule' they will in turn 
•resemble those found in disease there. Thus a lesion under one of 
the motor centres will produce a monoplegia, while if deeper a hemi- 
plegia will result. Local convulsions occur only when there is an 
irritative lesion immediately below the cortex, and general convulsions 
only in disease causing increase of cerebral pressure, as, for example, 
tumor. If the lesion is extensive there may be hemianesthesia on the 
opposite side. Disease of the white matter of the occipital lobe may 
cause hemianopsia ; of the temporal lobe, auditory disturbance. The 
differential diagnosis between a cortical and subcortical lesion is often 
difficult and sometimes impossible. 



Fig. 154. 

CALL0S0 -MARGINALF, 




MAM MILARY BODY! OPTfc TRACT. 

ANTERIOR COMMISSURE 



Vertical section through the centre of the corpus callosum, showing the convolutions 
of the median surface of the hemisphere. (L. C. Gray.) 

The internal capsule is the most frequent seat of cerebral disease, the 
lesion being most often vascular — embolism, or rupture of an artery. 
If the lesion is situated in the anterior third between the caudate 
nucleus and the lenticular nucleus, so far as known no definite symptoms 
result, but if it is in the middle third we have hemiplegia of the common 
type. The lower face, the tongue, the arm, and the leg on the opposite 
side are all affected, and if the palsy be right-sided there is at the begin- 
ning defect of speech. There may also be at the first deviation of the 
head and eyes, but never permanent palsy of any cranial nerve. Later on 
rigidity develops in the muscles, the knee-jerk is increased and ankle- 
clonus appears. Sometimes the hemiplegia is not complete, for if the 
lesion is small many fibres may escape, but there is practically never a 
true monoplegia. The sensory fibres from the cortex pass through 
the posterior third, and consequently if it be involved hemianesthesia re- 
sults, and there may be hemianopsia and loss of smell on the anaesthetic 
side. 



DISEASES OF THE NERVOUS SYSTEM. 



801 



The Corpus Striatum and Optic Thalamus. Lesions of the basal gan- 
glia give no diagnostic symptoms unless the internal capsule is involved. 

The Corpora Quadrigemina are closely connected with the optic- 
nerve fibres, the tegmentum, the superior and middle cerebellar 
peduncles, the pineal gland, the pulvinar, and the nuclei and fibres of 
the ocular nerves. In consequence, disease in this region is accom- 
panied by numerous and varying symptoms. Ataxic gait, similar to 
that present in cerebellar disease, ophthalmoplegia, and nystagmus are 
somewhat characteristic symptoms. 



Fig. 155. 




Diagram to show the relative position of the several motor tracts in their course from the cortex 
to the eras. The section through the convolutions, is vertical ; that through the internal capsule, 
I C, horizontal ; that through the crus is again vertical. C N, caudate nucleus ; O TH, optic 
thalamus ; L 2 and L 3, the middle and outer parts of the lenticular nucleus , fa I, face, arm, and 
leg fibres. The words in italics indicate the corresponding cortical centres. (Gowees.) 

The Crus Cerebri is in close anatomical relation with the oculo-motor 
nerve, as is shown in the diagram. We find, therefore, characteristic 
symptoms in disease. There is always oculo-motor palsy on the same side 
as the lesion and hemiplegia on the opposite side, both coming on at once. 
If there is anaesthesia on the palsied side the tegmentum is also involved. 

Pons. The symptoms depend upon the level at which the lesion is 
situated. The fibres of the facial nerve decussate higher up than those 
of the pyramidal tract, and consequently a lesion in the lower part will 
cause facial palsy on the same side and palsy of the leg and arm on the 
opposite side (alternating paralysis). If the lesion is above the facial 
nerve decussation there will result hemiplegia of the opposite side, 

51 



802 



SPECIAL DIAGNOSIS. 



including the face — distinguishable, however, from the typical hemiplegia 
from disease of the internal capsule by the fact that all the branches of 
the facial are affected, and that there may be, though rarely, reaction of 
degeneration. Bilateral lesions may cause bilateral facial palsy, or 



Fig. 156. 



r.k: 




Cross section through the region of the anterior corpora quadrigemina. qu.a., anterior corpora 
quadrigemina ; g.c, gray matter around the aqueduct of Sylvius ; nlll, nucleus of the third nerve ; 
hi. posterior longitudinal bundle ; r.k., red nucleus (tegmentum) : s n, substantia nigra (locus 
niger) ; p, cerebral peduncle. (Hirt.) 

bilateral palsy of the legs or of all four extremities. The local 
diagnosis cannot often, in such cases, be made with certainty. Convul- 
sions often occur in acute lesions. There is sometimes anaesthesia in 
the area of the trifacial. 

Fig. 157. 




Diagram showing the decussation of the fibres going to the extremities, and of those going to the 
face in the pons and medulla oblongata. F, facial fibres ; E, fibres going to the extremities; P, 
pons ; 0, medulla oblongata ; pyx, decussation of the pyramidal tracts ; a, a focus in the upper ; 
b, a focus in the lower part of the pons (the latter is situated helow the decussation of the facial 
fibres). (Hirt.) 



DISEASES OF THE NERVOUS SYSTEM. 



803 



Cerebellum. The hemispheres may be extensively diseased without 
giving rise to any symptoms. The characteristic symptom of disease 
of the middle lobe is disturbance of equilibrium and incoordination. 
The gait resembles that of a drunken mau. Giddiness and vomiting 
sometimes occur, but are of no localizing value. Nystagmus is frequent 
in cases of tumor. The knee-jerk is often absent, or it may be sometimes 
absent and sometimes present. If the pyramidal tracts are pressed 
upon, the reflexes are increased and there is weakness in the corre- 
sponding extremities. There may be palsy of the cranial nerves, diffi- 
culty in articulation due to pressure on the medulla, and occasionally 
epileptiform convulsions. If the middle peduncle is affected by an irri- 
tative lesion, quite characteristic symptoms result. " Forced movements" 
occur — that is to say, the body is involuntarily rotated upon its long 
axis, and the patient may have an irresistible tendency to lie on one 
side. There are no diagnostic symptoms of disease of the superior and 
inferior peduncles. Disease of one side of the pons may cause symp- 
toms similar to those of cerebellar trouble. 



Fig. 158. 




Diagram showing the different tracts of the cord. (Gowees.) 



Medulla Oblongata. If the nuclei in the floor of the fourth ventricle 
are diseased, bulbar palsy, which is described on page 844, results. It 
must be remembered that bilateral lesions in the lowest part of each 
ascending frontal convolution may cause symptoms indistinguishable 
from those of true bulbar palsy. 

Spinal Localization. 

The localizing symptoms in disease or injury of the cord vary with 
the level at which the lesion is situated and with the part of the 
transverse area involved. 

A total transverse lesion causes, of course, total paralysis of all 
parts below, including the bladder and rectum, with anaesthesia. If 



804 



SPECIAL DIAGNOSIS. 



Ci 



ID 



situated above the lumbar enlargement, the knee-jerk is increased, the 
legs become spastic, and ankle clonus appears on account of secondary 
, cn degeneration of the lateral tracts. If the 

lumbar enlargement is involved the reflexes 
are abolished and the palsy is flaccid. Much 
finer local diagnosis can be made by a study 
of Fig. 159, and of the table of the func- 
tions of the different segments of the cord 
which I quote from M. Allen Starr. It is 
important to remember that the segments 
of the cord do not correspond to the ver- 
tebrae after which they are named. 

Unilateral lesions produce palsy on the 
same side, with increased reflexes and 
^s-fa^^z^ 2 rigidity, and on the opposite side anaesthesia, 
2 ^Lff^J reaching not quite up to the seat of lesion. 

There may be some palsy on the side oppo- 
site the lesion on account of some fibres of 
the lateral pyramidal tract not having 
decussated. If the lesion is situated below 
the point of decussation of the sensory fibres 
anaesthesia will be upon the same side as the 
palsy. 

Antero -lateral White Columns. Disease 
of this area causes loss or diminution of 
voluntary movement, descending lateral 
degeneration, increased reflexes, and rigidity 
of the muscles. We find this condition in 
primary lateral sclerosis. If the motor 
cells in the anterior horn be also degen- 
erated, wasting is added to the other symp- 
toms, and as it progresses the increase of 
the reflexes and the rigidity disappears, 
and we have a flaccid palsy. This condi- 
tion of palsy with rigidity in some muscles 
and palsy with wasting in others is found 
in amyotrophic lateral sclerosis. 

Posterior White Columns. If the postero- 
external columns be affected there results 
muscular incoordination, with no loss of 
power, lancinating pains, abolished knee- 
jerk, and impaired sensation. Locomotor 
ataxia is the type of disease in this region. 
The symptoms of disease of the postero- 
median columns are unknown. 

Anterior Horns. The large cells in the 
anterior horns are the trophic cells of the 
nerves proceeding from them. Disease of 
them, therefore, is followed by muscular 
There is also, of course, palsy, 



12 



.11 



1 L 



.IS 



Diagram showing the relations of 
the vertebral bodies and spines to 
the segments of the cord and to 
the exit of the nerves. (Gowers.) 



wasting. 



Segment. 


Muscles. 


Reflex. 


Sensation. 


II. and III. 
c. 


Sterno-mastoid. 
Trapezius. 
Scaleni aud neck. 
Diaphragm. 


Hypochondrium(?). 

Sudden inspiration produced 
by sudden pressure beneath 
the lower border of ribs. 


Back ot head to vertex. 
Neck. 


IV. c. 


Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 
Supinator longus. 
Rhomboid. 

Supra- and infra-spinatus. 


Pupil. 4th to 7th cervical. 
Dilatation of the pupil pro- 
duced by irritation of neck. 


Neck. 

Upper shoulder. 
Outer arm. 


V. c. 


Deltoid. 
Biceps. 

Coraco-brachialis. 
Supinator longus. 
Supinator brevis. 
Rhomboid. 
Teres minor. 

Pectoralis (clavicular part). 
Serratus magnus. 


Scapular. 

5th cervical to 1st dorsal. 

Irritation of skin over the sca- 
pula produces contraction of 
the scapular muscles. 

Supinator longus. 

Tapping its tendon in wrist 
produces flexion of forearm. 


Back of shoulder and 
arm. 

Outer side of arm and 
forearm, front and 
back. 


VI. c. 


Biceps. 

Bracbialis anticus. 
Pectoralis (clavicular part), 
Serratus magnus. 
Triceps. 

Extensors of wrist and ringers. 
Pronators. 


Triceps. 

6th to 7th cervical. 

Tapping elbow tendon pro- 
duces extension of forearm. 

Posterior wrist. 

6th to 8th cervical. 

Tapping tendons causes ex- 
tension of hand. 


Outer side of forearm, 

front and back. 
Outer half of hand. 


VII. c. 


Triceps (long head). 
Extensors of wrist and fingers. 
Pronators of wrist. 
Flexors of wrist. 
Subscapular. 
Pectoralis (costal part). 
Latissimus dorsi. 
Teres major. 


Anterior wrist. 

Tapping anterior tendons 

causes flexion of wrist. 
Palmar. 7th cervical to 1st 

dorsal. 

Stroking palm causes closure 
of fingers. 


Inner side and back of 
arm and forearm. 

Radial half of the 
hand. 


VIII. c. 


Flexors of wrist and fingers. 
Intrinsic muscles of hand. 




Forearm and hand, in- 
ner half. 


I. D. 


Extensors of thumb. 
Intrinsic hand muscles. 
Thenar and hypothenar emi- 
nences. 




Forearm, inner half. 
Ulnar distribution to 
hand. 


II. to XII. 
D. 


Muscles of back and abdomen. 
Erectores spinse. 


Epigastric. 4th to 7th dorsal. 

Tickling mammary region 
causes retraction of the epi- 
gastrium. 

Abdominal. 7th to 11th dorsal. 

Stroking side of abdomen 
causes retraction of belly. 


Skin of chest and abdo- 
men, in bands run- 
ning around and 
downward corre- 
sponding to spinal 
nerve. 

Upper gluteal region. 


I. L. 


Ilio-psoas. 
Sartorius. 

Muscles of abdomen. 


Cremasteric. 1st to 3d lumbar. 
Stroking inner thigh causes 
retraction of scrotum. 


Skin over groin and 
front of scrotum. 


II. L. 


Ilio-psoas. Sartorius. 
Flexors of knee (Remak). 
Quadriceps femoris. 


Patellar tendon. 
Striking tendon causes exten- 
sion of leg. 


Outer side of thigh. 


III. L. 


Quadriceps femoris. 
Inner rotators of thigh. 
Abductors of thigh. 




Front and inner side 
of thigh. 


IV. L. 


Abductors of thigh. 
Adductors of thigh. 
Flexors of knee (Ferrier). 
Tibialis anticus. 


Gluteal. 

4th to 5th lumbar. 
Stroking buttock causes 
dimpling in fold of buttock. 


Inner side of thigh and 

leg to ankle. 
Inner side of foot. 


V. L. 


Outward rotators of thigh. 
Flexors of knee (Ferrier). 
Flexors of ankle. 
Extensors of toes. 




Back of thigh, back of 
leg, and outer part of 
foot. 


I. to H. s. 


Flexors of ankle. 
Long flexors of toes. 
Peronei. 

Intrinsic muscles of foot. 
Perineal muscles. 


Plantar. 

Tickling sole of foot causes 
flexion of toes and retraction 
of leg. 

Foot reflex. Achilles' tendon. 
Over-extension of foot causes 
rapid flexion; ankle clonus. 
Bladder and rectal centres. 


Back of thigh. Leg and 

foot, outer side. 
Skin over sacrum. 
Anus. 

Perineum. Genitals. 



806 



SPECIAL DIAGNOSIS. 



because these cells are, if one may say so, a way-station between the 
periphery and the cortex. And as they also are a link in the reflex 
arc, the muscle reflexes are abolished. Wasting is the most important 
symptom, for from it we can say positively that the anterior horns are 
affected. A short time after the onset, too, reaction of degeneration 
appears in the muscles. There may be slight wasting in cerebral palsy, 
but it is simply from disuse, and reaction of degeneration is never 
present. The extent of the palsy and wasting depends upon the 
extent of cord involved. It may be monoplegic, or several or all 
extremities may be affected. 

Diseases of the Cranial Nerves. Examination of the 
Functions of the Cranial Nerves. 

Olfactory Nerve. A rhinoscopic examination should always be 
made to discover whether local disease exists, since this may destroy all 
sense of smell. Irritant substances must not be used in examining, 
since they stimulate the trifacial nerve. Oil of cloves and peppermint or 
any of the essential oils are the best. Each nostril should be examined 
separately. Disturbance of function may arise from a lesion auy where 
between the periphery and the cortical origin. 

Anosmia, loss of the sense of smell, may be caused by acute or chronic 
nasal catarrh ; abnormal dryness of the mucous membrane from disease 
of the trifacial ; traumatism of the bulbs or nerves ; meningitis or tumor 
causing pressure upon or inflammation of the bulbs or nerve trunks ; 
and finally, lesions of the olfactory centre, placed by Ferrier in the 
uncinate gyrus. It is frequently met with in hysteria, and is sometimes 
seen in workers in strong-smelling substances. 

Parosmia, subjective sensation of smell, is found among the insane 
and in cases of migraine, tic douloureux, epilepsy, hysteria, and tabes 
dorsal is. Usually the odors are unpleasant. 

Hyperosmia, increased acuteness of smell, occurs in hysteria. It may 
be so marked as to make it possible for the patient to recognize persons 
by smell alone. 

Optic Nerve and Tract. This is the most important of the 
cranial nerves in relation to general diseases, especially those of the 
nervous system. 

1. Retinal Lesions, (a) Retinitis sometimes occurs as an idiopathic 
affection, but more frequently it is found in association with Bright's 
disease, syphilis, leukaemia, and severe ausemia. It occurs occasionally 
in diabetes, purpura, and chronic lead-poisoning. Whatever the cause, 
there are seen on ophthalmoscopic examination of the retina white spots 
and patches of various sizes and distribution, due for the most part to 
degenerative processes and hemorrhages. The latter are in the nerve- 
fibre layer and often follow the course of bloodvessels. When recent 
they are bright red in color, when old, black. 

Albuminuric retinitis occurs only in chronic renal disease. It is most 
frequent in granular kidney, least so in lardaceous disease. It may be 
present when there is little or no albumin in the urine, and practically 



DISEASES OF THE NERVOUS SYSTEM. 



807 



is never coexistent with functional albuminuria. Its presence proves 
organic renal disease. Gowers distinguishes four types — the degenera- 
tive, the hemorrhagic, the inflammatory, and the neuritic, according as 
white spots of degeneration, extravasations of blood, parenchymatous 
retinal inflammation, or inflammation limited to the optic nerve pre- 
dominates. 

b. Functional blindness, toxic amaurosis, occurs quite often in uraemia, 
sometimes in acute or chronic lead-poisoning, and occasionally from 
quinine. In hysteria there may be blindness in one or both eyes, but 
more often there is only a marked decrease in visual acuity. In this 
condition ophthalmoscopic examination reveals nothing. 

Tobacco amblyopia is gradual in onset and equal in both eyes. It is 
characterized by defect in the centre of the field of vision, a central 
scotoma. The scotoma is relative, not absolute ; vision is dimmed, not 
lost, and the failure is greater for red and green than for white. The 
eye-grounds may be normal, but if tobacco be persistently used, atrophy 
of the disk may result. 

Nyctalopia, or night-blindness, is the condition in which objects are 
clearly seen in a bright light, but are invisible in the shade or in 
twilight. In hemeralopia the reverse condition exists. 

Retinal hyperesthesia occurs in hysteria and rarely in retinitis. 

Optic Neuritis. (Choked disk, papillitis.) The disk is swollen 
and hypersemic, its edges are blurred, and a striated or grayish hazi- 
ness spreads over its face and out upon the retina. If the swelling be 
great there is left a complete atrophy upon its subsidence. In the early 
stages there is often no disturbance of vision, and even when the 
inflammation is quite severe sight may for a considerable time be quite 
good. 

Rarely papillitis is idiopathic. It occurs sometimes in anaemia and 
lead-poisoning, not uncommonly in Bright's disease as a neuro-retinitis, 
and commonly in meningitis and tumor of the brain. Its frequent 
presence in the last disease renders it of great diagnostic value. It 
must be remembered, however, that the presence of papillitis gives 
no information as to the locality or pathological nature of a brain 
tumor. 

Optic Atrophy may result from alcohol, lead-poisoning, diabetes, 
and the specific fevers. Many cases are associated with spinal cord 
diseases, particularly locomotor ataxia. Secondary atrophy is most 
commonly the result of papillitis, but it may result from cortical brain 
disease or pressure on the chiasma or nerves. 

The disk is pale or bluish or grayish, and its outlines are distinctly 
marked off. Visual acuity is lessened, color perception is altered, and 
the field is contracted. There is no pain and seldom photophobia. 
Prognosis is usually bad. 

Diseases of the Optic Chiasm and Tract. There is a semi- 
decussation of the optic nerves at the chiasm. The fibres from the 
outer half of each retina pass to the centre on the same side, while 
those on the inner half cross and pass to the centre of the opposite 
side. Remembering this, the symptoms resulting from lesion of the 
chiasm or tract are easily understood. 



808 



SPECIAL DIAGNOSIS. 



Unilateral Lesion of the Tract. If the lesion is situated at, say, b, 
Fig. 161, there will result loss of function of the temporal half of the 
right and nasal half of the left retina, so that the patient sees objects 
only on the right side. This condition is called lateral or homonymous 
hemianopia. 

Fig. 160. 




Diagram showing the course of the optic fibres in the chiasm. (Bxrt.) 

Lesion of the Chiasma. If the ceutral portion of the chiasma, made 
up of decussating fibres from the nasal sides of the retinas, be alone in- 
volved, there will result loss of vision in the outer half of each field — 
temporal hemianopia. If the lesion involves not only the central por- 
tion but also the direct fibres on one side, there results total blindness in 
one eye and temporal hemianopia in the other. Finally, if the entire 
chiasm is involved total blindness results. If the lesion affects the 
outer part of the chiasma, involving the fibres going to the temporal 
halves of the retinae, blindness results in the nasal field — nasal hemi- 
anopia. 

Lesion of the Tract and Centres. The optic tract, after crossing the 
crus to the hinder part of the optic thalamus, divides into two branches, 
one going to the thalamus and external geniculate bodies and to the an- 
terior quadrigeminal bodies, from which fibres pass into the hinder part 
of the internal capsule, and, entering the occipital lobe, form the fibres 
of the optic radiation terminating in the cuneus, the perceptive visual 
centre, while the fibres of the other branch pass to the internal genicu- 
late bodies and the posterior quadrigeminal bodies. It is held by some 
physiologists that the visual centre is not confined to the occipital lobe, 
but includes the occipito-angular region. 

A lesion anywhere in the tract from the chiasma to the cortex will 
of necessity produce lateral hemianopia. To sum up, the lesion may 
be in the tract itself, in the region of the thalamus, in the corpora 
quadrigemina, in the fibres passing from the latter to the occipital 
lobe, either in the hinder part of the internal capsule, or in the white 
fibres of the optic radiation, or finally in the cuneus. Bilateral disease 
in any of these situations will of course produce blindness in both eyes. 

Can we locate more closely the seat of the lesion ? In some cases, 
yes. If it is in the posterior part of the internal capsule, hemi- 
anesthesia of the opposite side, and if it extends far enough forward 
in the capsule, hemiplegia, will be associated with the hemianopia. 
Again, it has been found by Wernicke that if a beam of light is thrown 
laterally into a hemianopic eye, in a certain proportion of cases, on the 
blind side, the pupil will not contract. Now the light-reflex of the 



DISEASES OF THE NERVOUS SYSTEM. 809 

pupil depends upon the integrity of the retina, of the fibres of the nerve 
and tract, and of the nerve centre in the geniculate bodies which re- 
ceives the impression and transmits it to the third nerve, along which 



Fig. 161. 

LEFT VISUAL FIELD. RIGHT VISUAL FIELD. 
Fixation Point. Fixation Poo 'it. 




The optic and visual tracts. N, lesion causing nasal hemianopia ; T, lesion causingftemporal 
hemianopia ; H, lesion causing bilateral heteronymous hemianopia ; B, lesion of tract causing 
homonymous hemianopia. (Starr.) 



810 



SPECIAL DIAGNOSIS. 



the motor impulse passes to the iris. If then we find, on examining 
the pupil by the method detailed below, that there is pupillary inaction 
on the side corresponding to the blind half of the retina, we are justi- 
fied in saying that the lesion is very probably in the geniculate bodies 
or anterior to them, while, if both sides of the pupil respond, it is 
posterior. The test is a delicate one, not easily obtained, and according 
to recent research not always to be relied on. Seguin uses the following 
method : 

" The patient being in a dark room, with the lamp or gaslight 
behind his head in the usual position, I bid him look over to the other 
side of the room, so as to exclude the accommodative iris movements 
(which are not necessarily associated with the reflex). Then I throw a 
faint light from a plane mirror or from a large concave mirror held 
well out of focus upon the eye, and note the size of the pupil. With 
my other hand I now throw a beam of light, focussed from the lamp 
by an ophthalmoscopic mirror, directly into the optical centre of the 
eye ; then laterally in various positions and also from above and below 
the equator of the eye, noting the reaction at all angles of incidence of 
the ray of light." 

Hemianopia also occurs without discoverable organic lesion, as, for 
example, in hysteria and migraine. Lesion of the angular gyrus seems 
to produce crossed amblyopia, that is, dimness of vision of the eye of 
the opposite side, with contraction of the field of vision, more often 
than hemianopia. Lesions in this region are also associated with mind- 
blindness — the condition in which, while the patient sees, he does not 
recognize objects. 

The Oculomotor Nerve. Motor Nerves of the Eyeball. The 
third nerve supplies the levator palpebral superioris, the superior rectus, 
the internal and inferior rectus, the inferior oblique, the ciliary muscle, 
and the constrictor of the iris. Lesion of it may produce either spasm 
or palsy. It may be affected either in its nucleus or along its course. If 
the nucleus be affected, there is usually associated disease of the nuclei 
of the other ocular nerves. In the nerve itself there may be neuritis, or 
it may be involved by meningitis, tumors, or aneurism. Complete paraly- 
sis causes the following symptoms : The eye can be moved outward and 
a little downward and inward. There is divergent strabismus, causing 
diplopia, owing to the unopposed action of the external recti ; ptosis or 
drooping of the upper lid, due to the paralysis of the levator palpebrse ; 
the pupil, while of moderate size, does not contract to light, and power of 
accommodation is lost. The eyeball protrudes slightly on account of 
the palsy of the three recti. In many cases only one or more branches 
are affected. Thus we may have only palsy of the levator palpebrse 
and superior rectus, or of the ciliary muscle and iris. 

The remarkable condition in which at irregular intervals throughout 
life there recurs a complete oculo-motor palsy need only be men- 
tioned. In paralysis of the ciliary muscle (cycloplegia) there is loss of 
accommodation, so that while distant vision is perfect things near cannot 
be clearly seen without the aid of convex glasses. The condition is 
frequently met with in diphtheritic palsy and in tabes. 

The iris has three actions (Gowers) : 1. Reflex contraction of the 



DISEASES OF THE NERVOUS SYSTEM. 



811 



sphincter on exposure of the eye to light. 2. Reflex dilatation by the 
radiating fibres on stimulation of a cutaneous nerve. 3. Contraction 
on accommodation, usually, but not necessarily, associated with con- 
vergence. There are, therefore, three forms of paralysis of the iris 
(iridoplegia) : 

1. Accommodation, in which during accommodation the pupil does 
not diminish in size. To test this condition, it is simply necessary to 
make the patient look at a distant object and then at a near one, both 
being in the same line of vision so as to avoid any change in the 
amount of light entering the eye. 

2. Reflex, in which the pupil does not contract when exposed to light. 
Each eye must be examined separately, keeping the other cohered, since 
light entering one eye acts on both pupils. It is best tested by having 
the patient look at a distant object in a darkened room, and then bring- 
ing a light suddenly in front of the eye. If the light reflex be lost 
and the accommodation reflex is retained, we call it Argyll -Robertson 
pupil. 

3. Loss of Skin Reflex. Pinching or pricking the skin, say of the 
back of the neck, will in most healthy persons produce dilatation of the 
pupil, the afferent impulse being sent along the cervical sympathetic. 

Ordinarily in iridoplegia the pupils are small, but they may be of 
medium size. 

Nystagmus is a spasmodic condition of the muscles of the eye, pro- 
ducing rapid oscillations of the ball, usually horizontal, sometimes 
rotary, and rarely vertical. It is of little value as a symptom. It is 
found in many brain lesions, in albinism, and often in miners. 

Blepharospasm, spasm of the orbicularis palpebrarum, may cause only 
a twitching of the eyelids, or it may be so severe as to forcibly press 
the eyelids together, so that the patient cannot open them. 

Ptosis is of sufficient importance to require a more detailed descrip- 
tion. It may be congenital, in which case it is apt to be bilateral and 
partial, due to lesion of the third nerve or its nucleus, as mentioned 
above ; associated with cerebral disease without the other branches of 
third nerve being affected ; or hysterical. When the cervical sympa- 
thetic is paralyzed, the upper lid on the same side is a little lower than 
the other, due to the palsy of the fibres of Miiller. The movements of 
the lid are, however, unimpaired, and other symptoms of sympathetic 
palsy, such as contraction of the pupil, dilatation of the vessels of the 
surface, and altered secretion of sweat, are always present. Very rarely 
irritation of the fifth nerve will cause transient ptosis. Occasionally, 
especially in sickly women, there is a condition called morning ptosis, 
in which for some minutes after waking it is impossible for the patient 
to open the eyes. 

The Trochlear or Pathetic Nerve. Fourth Nerve. The supe- 
rior oblique muscle is supplied by the fourth nerve. Palsy of it causes 
defect in downward and inward movement, causing diplopia on looking 
downward. 

The Trigeminus. The Fifth Nerve is the great sensory nerve of the 
face. It supplies the entire side of the face, the conjunctiva, the mucous 
membrane of the lip, gums, tongue, hard and soft palate, and of the 



812 



SPECIAL DIAGNOSIS. 



nose. It supplies the anterior two-thirds of the tongue with the nerves 
of taste. Its motor division supplies the muscles of the lower jaw, 
temporal, masseter, pterygoid, the mylo-hyoid, aud the posterior belly of 
the digastric. ^ 

Paralysis is caused by (1) hemorrhage or other lesion in the pons; 
(2) tumor at the base of the brain, meningitis, or caries ; (3) the 
branches may be aifected in their course — the first by tumor pressing 
on the cavernous sinus, the second and third by tumor invading the 
spheno-maxillary fossa ; (4) primary neuritis, which is very rare. 
Secondary neuritis by extension is of course common. 

Symptoms. Sensory. Anaesthesia is present over the entire distribu- 
tion or in one branch, according as the entire trunk or only one branch 
is affected. There is also loss of taste in the anterior two-thirds of 
the tongue, and of smell in the corresponding nostril. The salivary, 
lacrymal, and buccal secretions may be lessened. If the Gasserian 
ganglion is affected the eye inflames, the cornea becomes cloudy and may 
ulcerate. Herpes sometimes develops. The anaesthesia is apt to be 
preceded by darting, burning pain. 

Motor. There is inability to masticate on the affected side. If the 
pterygoid be affected the jaw when depressed deviates toward the palsied 
side. 

Spasm, of the muscles of mastication produces trismus. It may be 
clonic or tonic and may occur in general convulsions, or, but this is rare, 
as an isolated affection. In the tonic form the jaws cannot be opened. 
Clonic spasm is exemplified in chattering teeth. 

Gustatory. While as stated above there is apt to be loss of taste in 
the anterior two-thirds of the tongue, this is not always so. These 
fibres may escape or the lesion be situated within the pons when these 
fibres are separated from those of sensation. 

Neuralgia. (Trifacial neuralgia, tic douloureux, prosopalgia.) The 
trifacial is more frequently the seat of neuralgia than any other nerve. 
All the branches are rarely affected together. The ophthalmic is most 
often affected, producing the so-called brow ague, supra-orbital neuralgia. 
The pain radiates from the supra-orbital notch over the anterior half of 
the head and may extend to the side of the nose. The supra-orbital 
notch, or the nerve just above it, is painful on pressure. In ocular 
neuralgia there is pain confined to the ball, or both eyes may be in- 
volved. In infra-orbital neuralgia, the second branch is affected and 
the pain extends from the orbit to the mouth and over the cheek. 
There are points painful on pressure over the infra-orbital foramen, 
over the malar bone, and above the gum of the upper jaw. 

If the third division be affected there is pain in the parietal region, 
the temple, the lower jaw, and the tongue. There are tender points at 
the inferior dental foramen, at the posterior part of the temporal region, 
and over the parietal eminence. 

The pain is always severe and its description varies with the powers 
of the patient, burning, tearing, boring, etc. When sudden and severe 
the reflex muscular spasm, the tic eonvulsif, occurs. 

The Motor Oculi Externus or Abducens. Sixth Nerve. The 
external rectus muscle is supplied by it. Palsy of it produces defect of 



DISEASES OF THE NERVOUS SYSTEM. 



813 



outward movement of the ball and consequent convergent strabismus. 
Diplopia occurs on looking to the paralyzed side. 

Acute Ophthalmoplegia. Acute Nuclear Palsy. Sudden paralysis of 
all the ocular muscles sometimes occurs from hemorrhage in the region 
of the nuclei. The apoplexy is usually fatal. It is unknown whether 
multiple neuritis ever affects the ocular nerves. If it does, the result- 
ing palsy would simulate nuclear disease. 

Chronic ophthalmoplegia may affect either the external or the internal 
eye muscles. In the first the levator muscles and the superior recti are 
first affected, later the others, so that finally the balls are immovable 
and the eyelids droop. The condition may persist for years. It is often 
associated with general paralysis and tabes dorsalis. In the second 
there is no pupillary reflex either to light or with accommodation. 
The two forms may occur together. 

Spasm of the Ocular Muscles. The varieties of spasm are grouped 
by Growers into five classes : 

1. Associated Spasm from Central Disease. In a paralyzing lesion 
of one hemisphere the eyes deviate toward this side because of the unop- 
posed influence of the opposite hemisphere. An irritative lesion of one 
hemisphere causes conjugate deviation due to spasm toward the opposite 
side. It occurs at the onset of unilateral convulsions. 

2. Irregular Spasm from Brain Disease. In irritating disease of the 
base of the brain, especially in meningitis, there may be spasm of one 
or more ocular muscles. 

3. Chronic spasm in individual muscles is very rare except in cases of 
secondary deviation. 

4. Hysterical Spasm. In fits of hysteria the eyes are usually directed 
upward and to one side, often concealing the cornea entirely, or there 
may be marked convergence, but never divergence. Convergence may 
persist during the interval. 

5. Paroxysmal spasm occurs in convulsive attacks. Cases are occa- 
sionally met with in which only one muscle is affected, there being at 
the same time momentary loss of consciousness. 

The Facial Nerve. The Seventh. Paralysis may result from 
lesion of the cortex, of the nucleus, or of the trunk. The cerebral form, 
that due to disease above the nucleus, is easily distinguished from the 
peripheral, BelPs palsy, by the persistence of normal electrical reactions 
in muscles and nerves, and by the non-involvement of the upper 
branches, so that the orbicularis palpebrarum and frontalis are spared. 
Again, voluntary movements are more impaired than emotional ones. 
Ordinarily also supra-nuclear disease causes not palsy of the face alone 
but a hemiplegia. 

Nuclear palsy rarely occurs alone, but is seen sometimes in tumors, 
chronic softening, and hemorrhage. In anterior poliomyelitis and 
diphtheria the nucleus may be affected. The condition cannot be diag- 
nosticated from disease of the trunk. 

ii |In the peripheral form, BelPs palsy, all branches of the nerve are 
involved. The face on the affected side is motionless, the skin is 
smooth, the eye cannot be closed, and the lower lid droops. The angle 
ot the mouth droops and the lips on the affected side cannot be closed. 



814 



SPECIAL DIAGNOSIS. 



On movement the face is strongly drawn to the sound side. The 
patient cannot whistle, and he may have difficulty in pronouncing the 
labials. Food collects between the teeth and the cheeks. The tongue 
appears to be protruded to one side on account of the facial deformity. 
In the great majority of cases the uvula does not deviate. All reflex 
movements are lost. There is no change in the electrical reactions in 
slight cases. In severe ones degeneration reaction is found. If the 
lesion is situated between the geniculate ganglion and the origin of the 
chorda tympani there is loss of the sense of taste in the anterior part 
of the tongue on the affected side. Hearing may be impaired usually 
on account of preceding ear disease. In old cases there occurs a sec- 
ondary contraction of the muscles on the affected side, which draws the 
face to that side, increases wrinkling, and makes it appear while at 
rest that the diseased is the healthy side. 

Double facial palsy is very rare, but may be caused by lesions at the 
base, in the pons, by disease in both ears, and possibly by disease of 
the nuclei or double cortical lesions. 

Spasm may involve a few or all of the muscles and may be bilateral. 
If the muscles around the eye be affected it is called blepharospasm. 
More often there is twitching of all the muscles of the side of the face 
and partial closure of the eye. 

The Auditory Nerve. The Eighth. Hearing is tested by the 
watch or a tuning-fork. Normally the instrument should be heard at 
an equal distance from either ear. If both sides are equally affected 
the hearing of the patient must be compared with that of a healthy 
person. In order to determine whether the deafness is neurotic or due 
to obstructive disease we test the sharpness of hearing through bone- 
conduction (Rinne's test). If the cause is middle-ear disease, impacted 
cerumen, or obstruction of the Eustachian tube, a vibrating tuning-fork 
placed upon the vertex will be heard much more intensely on the deaf 
side. In certain middle- ear diseases, however, as, for example, anky- 
losis of the bones, this does not hold true. 

Hypercesthesia of the Auditory Nerve. Very rarely in certain cases 
of facial paralysis, and not rarely in hysteria, there is abnormal acuteness 
of hearing (oxyacoia). In some individuals suffering from hemicrania 
or tic douloureux, and in meningitis, the hearing of certain sounds — for 
example, high musical notes and whistling, is accompanied by pain. 
Nervous patients often complain of subjective noises, buzzing, roaring, 
hissing, and singing— the so-called tinnitus aurium. 

Paralysis of the Auditory Nerve. No case of absolute unilateral 
deafness due to a focal lesion in a hemisphere has as yet been observed. 
Deafness from disease of the auditory nucleus is very rare. That due 
to disease of the peripheral nerve is much more common. We may 
have a rheumatic auditory paralysis similar to that of the facial nerve, 
or the deafness may be due to pressure from a tumor or inflammatory 
exudate at the base of the brain, or disease of the mastoid process of 
the temporal bone. The localization of the lesion is often extremely 
difficult. The only positive point is that labyrinthine disease is apt to 
be accompanied by vertigo, while in disease of the nerve trunk vertigo 
is absent. Deafness due to occupation is worthy of mention. It is 



DISEASES OF THE NERVOUS SYSTEM. 



815 



not uncommon in blacksmiths, boiler-makers, locomotive engineers, and 
firemen. In some instances the patients can hear better during the 
noise incident to their work than when the surroundings are absolutely 
quiet. 

Meniere's Disease. Aural Vertigo. We may define vertigo as a 
subjective feeling of motion referred by the patient either to his own 
body or to surrounding objects, with loss of equilibrium and without 
unconsciousness. 

In this disease, first described by P. Meniere in 1861, there is parox- 
ysmal vertigo, sometimes so sudden and intense as to throw the patient 
to the ground, tinnitus aurium, nausea, pallor, clammy sweat, and 
vomiting. The severity of the attacks varies greatly. There may be 
momentary unconsciousness. There is sometimes jerking of the eye- 
balls, nystagmus, or diplopia. The disease is paroxysmal in character, 
but slight vertigo and tinnitus are apt to persist between the attacks. 
Some deafness is present. The attacks may vary in frequency from 
several in a day to only one in several months. 

Paralyzing Vertigo. Gerlier describes a remarkable form of parox- 
ysmal vertigo accompanied by weakness, paresis in the extremities, 
drooping of the eyelids, marked lassitude and depression without un- 
consciousness. It occurs only in men and is epidemic in the Canton of 
Geneva. 

The Glossopharyngeal Nerve. The Ninth. This nerve sup- 
plies the posterior third of the tongue with nerves of taste. It sends 
motor branches to the stylo-pharyngeus and the middle constrictor of the 
pharynx, and branches of common sensation to the upper part of the 
pharynx. To test the sense of taste the eyes should be closed, the 
tongue protruded, and small quantities of bitter, sweet, sour, and salty 
substances applied to various parts. The sensation should be perceived 
before the tongue is withdrawn. 

We know but little about central diseases of this nerve. The situa- 
tion of its cortical centre is unknown. A central paralysis of taste 
manifesting itself only on the posterior third of the tongue has never 
been observed. Peripheral loss of taste (ageusia) may be caused by 
affections of the mucous membrane, and is often met with in fevers and 
the coated tongue of dyspepsia. Perversion of taste (parageusia) is 
found in hysteria and insanity. 

The Pneumogastric Nerve. The Tenth. This nerve supplies 
the pharynx, larynx, lungs, heart, oesophagus, and stomach. It may 
be compressed by tumors or inflammatory exudates. It has been tied 
in ligating the carotid and cut in removing tumors of the neck. Its 
nucleus may degenerate and the nerve may be the seat of neuritis. 

Pharyngeal Branches. These, with branches from the glossophar- 
yngeal, supply the muscles and mucosa of the pharynx. In paralysis 
of them, either from nuclear or peripheral disease, there is difficulty in 
swallowing, and the food does not pass into the oesophagus, but into the 
larynx and posterior nares. Spasm is always functional. 

Laryngeal Branches. The superior laryngeal nerve supplies the 
mucosa above the vocal cords and the crico-thyroid muscle. The 
recurrent laryngeal supplies the mucosa below the cords and all the 



816 



SPECIAL DIAGNOSIS. 



muscles of the larynx except the crico-thyroid and the epiglottidean. 
All the motor branches arise from the spinal accessory. 

Bilateral Abductor Paralysis. The posterior crico-arytenoids being 
involved, the glottis is not opened during inspiration ; the cords are 
close together, so that there is stridor. Phonation is unimpaired. The 
affection occurs in tabes, bulbar paralysis, and hysteria. 

Unilateral Abductor Paralysis. Pressure from an aneurism is the 
most common cause. The cord on the affected side does not move on 
inspiration. The voice is hoarse, and rarely there is dyspnoea. 

Adductor Paralysis. There is palsy of the lateral crico-arytenoid 
and arytenoid muscles. The cords cannot be brought together when 
phonation is attempted. 

The following table from Gowers shows the different conditions well : 



Symptoms. 


Signs. 


Lesion. 


No voice ; no cough ; stridor only 
on deep inspiration. 


Both cords moderately abducted 
and motionless. 


Total bilateral palsy. 


Voice low-pitched and hoarse ; no 
cough ; stridor absent or slight 
on deep breathing. 


One cord moderately abducted 
and motionless, the other mov- 
ing freely, and even beyond the 
middle line in phonation. 


Total unilateral palsy. 


Voice little changed ; cough nor- 
mal; inspiration difficult and 
long, with loud stridor. 


Both cords near together, and 
during inspiration not separ- 
ated, but even drawn nearer 
together. 


Total abductor palsy. 


Symptoms inconclusive ; little af- 
fection of voice or cough. 


One cord near the middle line not 
moving during inspiration, the 
other normal. 


Unilateral abductor palsy 


No voice ; perfect cough ; no stri- 
dor or dyspnoea. 


Cords normal in position and mov- 
ing normally in respiration, but 
not brought together on an at- 
tempt at phonation. 


Adductor palsy. - 



Laryngeal Spasm. The adductor muscles are affected. Under the 
name of laryngismus stridulus it is frequently met with in children. 
It is the cause of the laryngeal crisis in tabes. There is no cough nor 
hoarseness, but respiration ceases, the face becomes congested, there is a 
straggle for breath, and as the spasm relaxes there is a deep inspiration, 
with a loud crowing sound. 

Cardiac Branches. The heart's action is controlled by this nerve. 
Irritation may produce slowing of the pulse. In the case of Czermak 
it was possible to stop the heart for a few beats by pressing on a small 
tumor in the neck. If the nerve be palsied there may be increase in the 
frequency of the pulse. Normally the heart acts without consciousness 
participating. All sensations of cardiac palpitation and pain are con- 
veyed to the brain through this nerve. 

Pulmonary Branches. The motor branches supply the bronchial 
muscles. Asthma may be a neurosis of this nerve. 

G-astric and (Esophageal Branches. These supply all the motor 
fibres to the stomach and oesophagus. Vomiting is caused either by 
direct irritation of them or reflexly, as in meningitis. Gastralgia is due 
either to a cramp of the stomach or direct irritation of the peripheral 
ends. 



DISEASES OF THE NERVOUS SYSTEM. 



817 



The Spinal Accessory Nerve. The Eleventh. The internal 
branch joins the pneumogastrie nerve aud passes to the laryngeal 
muscles. The external branch supplies the sterno-mastoid and, iu part, 
the trapezius muscles. Disease of it causes complete palsy of the former 
and partial palsy of the latter muscle. The head is rotated with diffi- 
culty to the sound side. The shoulder droops a little, aud the angle of 
the scapula is rotated inward by the rhomboids and the levator anguli 
scapulse. There is difficulty in raising the arm, because the scapula 
cannot be fixed. There is no torticollis. 

Spinal accessory spasm (torticollis, wry-neck) may be congenital. 
The sterno-mastoid is atrophied, hard, and shortened. In almost all 
cases there is facial asymmetry, the palsied side being the smaller. 

Spasmodic torticollis may be tonic or clonic. In the former the 
occiput is drawn toward the shoulder of the affected side, the chiu is 
raised, and the face turned toward the sound side. In the latter the 
head is drawn forcibly every few minutes in the same direction. In 
some cases there is severe pain. The sterno-mastoid may be affected 
alone or with the trapezius, and quite frequently with the splenius, 
the scalenus and platysma myoides, the rectus, and the obliquus. 
In time the muscles become markedly hypertrophied. If the muscles 
of both sides are affected the head is drawn backward. This disease is 
usually considered as a functional neurosis, but it is probable that some 
cases are due to disease of the cortical centres. 

The Hypoglossal Nerve. The Twelfth. This is the motor 
nerve of the tongue and, to a great degree, of the muscles attached to 
the hyoicl bone. Palsy of the tongue may be due to supra-nuclear, 
nuclear, or infra-nuclear disease. In the first place there is hemi- 
plegia, no wasting, nor change in the electrical reactions. The tongue 
is protruded toward the affected side. In the second the lesion is apt 
to be bilateral, in which case the tongue lies motionless on the floor 
of the mouth, aud speech and deglutition are much interfered with. 
There is atrophy and reaction of degeneration. The condition is likely 
to be part of a general bulbar palsy. In the third only one nerve is 
affected, and wasting and reaction of degeneration are present. 

Rarely there occurs a clonic spasm, in which the tongue is thrust in 
and out many times in a minute. 

The Spinal Nerves. Neuritis. 

Traumatic injury, injury resulting from exposure to cold, and the 
injury that is inflicted by poisons, as that of rheumatism, gout, 
syphilis, lead, alcohol, and the toxins of specific diseases, as small- 
pox, typhoid fever, diphtheria, and other affections, may set up 
inflammation of the nerves. Neuritis may also be caused by direct 
action of bacteria, infection of the body having taken place in other 
situations. 

Symptoms. The inflammation may be very intense and involve a 
large number of nerves. One only may be affected. The process may 
be moderate iu degree. The symptoms, therefore, vary. The local 
symptoms are referred to the affected nerve and to the tissues in the area 

52 



818 



SPECIAL DIAGNOSIS. 



of its distribution. Pain is the most common. It is of a boring or 
burning character, and is worse at night. It is increased by movement, 
by pressure, and by position. It may radiate to distant parts. The 
pain may not be confined to the nerve alone, but extend to the structures 
supplied by the nerve. The bone may be tender on pressure. The 
nerve, if accessible, is found on palpation to be swollen and extremely 
tender. Vasomotor symptoms are observed. The skin over the affected 
nerve is red, and may be cedematous. Eruptions may occur in the 
course of the nerve. In chronic cases trophic changes in the skin take 
place. Changes are observed in the nails (see page 133). Numb- 
ness, tingling, and other paresthesia? are complained of. The area of 
nerve supply maybe hy per wsthetic ; sometimes sensation is lost in small 
areas. Wasting of the muscles occurs ; paresis, if not paralysis, is 
seen. 

The general symptoms are moderate, although fever may be high and 
at its onset preceded by a chill. 

In chronic neuritis, pain is the most common symptom. Trophic 
changes are more liable to occur. A wasting of the muscles ensues. 
Reactions of degeneration are determined by electricity. 

Diagnosis. Neuritis must be distinguished from neuralgia. In the 
latter the pain is intermittent, the nerve trunks are not tender, while 
points of pain are more prominent in local situations. The diminution 
of sensation is an indication of the occurrence of neuritis. 

Inflammation of Special Nerves. The following nerves are fre- 
quently the seat of neuritis: 1. The phrenic nerve — rarely (see 
Dyspnoea). 2. Other nerves of the brachial plexus. One nerve or 
the entire plexus may be affected. The symptoms are the symptoms of 
neuritis and the symptoms that occur in paralysis of muscles supplied 
by the special nerve affected, a. The posterior thoracic nerve. The 
serratus muscle is affected. The paralysis is recognized by recession of 
the posterior edge of the scapula from the thorax when the arm is put 
forward, b. The supra- scapular nerve. There is paralysis of the 
supra- and infra-spinatus muscle. Ability to rotate the humerus 
outward is lost. c. The circumflex nerve. The deltoid muscle is 
paralyzed. Power of raising the arm is lost. When the muscle 
atrophies, the shape of the shoulder is changed. It must not be con- 
founded with ankylosis of the joint. In ankylosis the scapula moves 
when the arm is moved. In paralysis it remains fixed, d. The 
musculo -cutaneous nerve. The flexors of the elbow are affected. The 
biceps and brachialis muscles are paralyzed, e. The musculo- spiral 
nerve. The triceps, the muscles in the back of the forearm, and the 
extensors of the wrist and fingers are affected. The symptoms are 
those of wrist-drop when the extensors are affected. The triceps 
muscle often escapes because the nerve is affected below the point from 
which the branches which supply this muscle pass off. The power of 
supination is also lost. The muscles waste ; the extreme flexion causes 
prominences about the wrist and hand. There is marked degenerative 
reaction. Sensation is variable ; it may be lost. The affection is 
usually unilateral, whereas in lead-poisoning it is bilateral. /. The 
median nerve. The flexors of the fingers, the abductors and flexors of 



DISEASES OF THE NERVOUS SYSTEM. 



819 



the thumb, the pronators and the radio-flexor of the wrist are affected. 
Pronation is markedly interfered with ; flexion of the second phalanges 
on the first is lost. The wrist is flexed toward the ulnar side. g. The 
ulnar nerve. The ulnar flexor of the wrist, the ulnar half of the deep 
flexor of the fingers, the muscles of the little finger, the interossei, 
and adductors of the thumb are affected. Its sensory areas are also 
affected. 

3. The nerves of the lower limb. The symptoms are limited to 
the individual nerve trunks and their respective functional areas. The 
nerve of the leg most frequently affected is the sciatic — a neuritis of 
common occurrence. The onset is sudden, the pain is extreme ; there 
is flexion of the leg in order to prevent tension of the nerve. The 
pain is intense in the course of the nerve trunk from a point above the 
hip-joint to the back of the foot. Tenderness on pressure is extreme. 
Abnormal sensations are very common. The muscles, especially the 
calf muscles, become flabby, and sometimes waste. 

It must not be forgotten that in paralysis from neuritis in the nerves 
both of the arms and the legs, spinal cord lesions are closely simulated. 
In the arms, particularly, muscular palsy, wasting, and anaesthesia are 
often of spinal origin. The unilateral seat of the disease, and the local 
symptoms of the neuritis aid in the diagnosis. Neuritis must be dis- 
tinguished from writer's cramp and other occupation neuroses. 

Multiple Neuritis. 

Multiple neuritis is a disease in which a number of nerves become 
inflamed simultaneously or successively. The nerves most frequently 
affected are those of the arms and legs, particularly the musculo-spiral 
and the anterior tibial ; these become the seat of pain, swelling, and 
tenderness, and the extensor and flexor muscles supplied by them 
paralyzed, producing wrist- and foot-drop. Excluding diphtheria, lep- 
rosy, and the Japanese disease known as kakke-kakke, the most com- 
mon causes are chronic alcoholism, cold, and exposure. It is most 
common in middle life, and females are said to be more frequent victims 
than males. It may be acute or subacute in its onset ; when acute there 
may be marked fever with rigors. The initial symptoms are usually 
tingling, numbness, and dull pains in the limbs ; the pains increase in 
severity and become shooting and burning, as in simple neuritis. The 
muscles of the limbs are tender to pressure, and the nerve trunks them- 
selves highly sensitive and sometimes perceptibly swollen. The affected 
muscles lose power, waste, and show degenerative reactions. The skin 
is at first hyperassthetic, but subsequently often becomes anaesthetic to 
touch while hyperaesthetic to pain. The deep reflexes are lost, and 
vasomotor and trophic changes in the skin and its appendages and in 
the joints sometimes occur. 

As a rule, the disease increases in severity for a few weeks and then 
slowly improves, but palsy may persist for months ; it usually improves 
first in the legs and last in the arms. Death may occur from extension 
of the palsy to the respiratory muscles, but is rare. 



820 



SPECIAL DIAGNOSIS. 



Diseases of the Spinal Cord and its Membranes. Meningitis. 

Inflammation of the dura mater (external meningitis) may be acute or 
chronic. The acute form is characterized by local pain in the back, 
increased by motion and pressure ; by rigidity of the muscles ; by radi- 
ating pains in the trunk or limbs, due to pressure upon the nerve roots, 
and hence called root-pains ; and by hyperesthesia, perhaps followed by 
anaesthesia, of the skin. In proportion to the extent of the irritation of 
the nerve roots, numbness, tingling, formication, twitching, and spasm 
accompany the pain ; and if compression be sufficient, paralysis of motion 
results, with or without loss or perversion of sensation. The paralyzed 
muscles are flaccid, and reflex action is abolished. Urine and faeces may 
escape involuntarily from paralysis of the respective sphincters, and if 
the patient survive long enough bedsores may form. The disease is 
febrile, and, should pus form, the fever becomes high and is accompanied 
by chills and sweating. 

As the disease is almost always consecutive to disease of the verte- 
brae, such as caries or traumatism, or to extension of suppuration from 
adjacent tissues, as in bedsores, the early symptoms are liable to be 
overlooked in the primary affection. 

Gowers says that in case of apparently primary meningitis a careful 
watch should be kept on the tissues of the back ; any sign of deep 
oedema in the muscles beside the vertebral column, in such a case, is 
probable evidence of commencing purulent inflammation extending 
from within, and the development of acute local inflammation in either 
the pleura, posterior mediastinum, back of the abdomen, or behind the 
pharynx, has the same significance. 

The chronic form is characterized by the same symptoms of local 
vertebral pain, radiating root-pains with disturbances of sensation, 
together with symptoms of pressure on the cord. The pain is less 
acute, and the course of the disease much longer. 

Inflammation of the pia and arachnoid {internal, or lepto-meningitis) 
may be acute or chronic. 

The acute form is characterized at its onset by chill, fever, and local 
vertebral pain, which are rarely preceded by other symptoms. The 
pain rapidly becomes intense, is aggravated by motion, and is felt over 
a considerable portion of the spine, but is often worse at some part. 
In addition to the local pain, there are root-pains of great intensity, 
shooting into the trunk and extremities. There is a tendency to 
muscular spasm, showing itself first in stiffness of the muscles of the 
back, often causing rigidity and retraction of the head, and sometimes 
opisthotonos. Elsewhere the muscular spasm is exhibited in painful 
cramp of the abdominal muscles and muscles of the extremities. The 
latter become rigid, painful on pressure, and are liable to painful croup- 
like spasms on motion. The skin is hyperaesthetic, and reflex action, 
both of the skin and muscles, is increased. The bowels are constipated 
and the urine retained, from spasm of the sphincters. Spasm of the 
chest muscles sometimes causes intense dyspnoea. Swallowing, also, 
may be difficult. If the inflammation extend to the medulla, cerebral 
symptoms are superadded, such as delirium and coma. If the disease 



DISEASES OF THE NERVOUS SYSTEM. 



821 



progresses unfavorably the irritative symptoms give way to paresis and 
then to paralysis, accompanied by loss of sensation and reflex action. 
Recovery at this stage may occur, with gradual abatement of the pain 
and s]ow regaining of muscular power ; or death may result from weak- 
ness and failure of respiratory power, or more slowly as the result of 
complications, such as bedsores aud nephritis. The disease may also pass 
into a subacute or chronic form, loss of power gradually taking the 
place of the irritative symptoms, and atrophy and contractions appearing. 
The final result may be a chronic myelitis, or complete but very gradual 
recovery. 

The disease is febrile, but the temperature may be only slightly 
above normal. The duration of the disease is from a few days to two or 
three weeks ; but disturbances of motion aud sensation may persist for 
months or even become permanent. 

The disease may be traumatic in origin, or may arise from exposure 
to cold or to heat, including long-continued exposure to the sun. It 
may also be secondary to an external meningitis or to a cerebral menin- 
gitis, or be septic in origin. 

Chronic meningitis differs widely in its symptoms from the acute 
form, particularly in the fact that spasm is almost wholly absent. 
There is local pain in the back which, as in acute meningitis, is increased 
by pressure and motion ; but the pain is not so acute. The muscles 
are more rigid than uormally, and there may be retraction of the head. 
Root-pains are severe and of a varied character. Hyperesthesia to pain 
and touch may be marked. Muscular twitchings may occur, but they 
are not pronounced, and rarely amount to spasms. The parts affected 
by the radiating pains will of course depend upon the seat of the 
lesion. 

After the lapse of weeks or months, loss of power occurs in the 
affected muscles. The radiating pain may continue or disappear. The 
paralytic phenomena are progressive, the muscles waste, reflex action is 
abolished finally, sensation is impaired, at least in the affected muscles. 
If the inflammation involves the lumbar enlargement reflex action is 
lost and atrophy of the legs occurs ; whereas if it is above the lumbar 
enlargement, the reflexes, if lost temporarily, are regained, and wasting 
of the leg muscles does not occur. 

Gowers says that in the trunk loss of reflex action with anaesthesia is 
of much diagnostic importance. There may also be some loss of 
coordination. 

Cervical hypertrophic pachymeningitis (Charcot and Joffroy) closely 
simulates progressive muscular atrophy. Its earlier stage is characterized 
by pain in the back of the head, neck, shoulders, and arms, followed by 
wasting of groups of muscles of the arm and hand, leading to the 
deformity known as main en griffe (claw-hand), and to weakness and 
wasting ot the muscles of the leg. 

Chronic syphilitic meningitis is characterized by a tendency of the 
inflammation to localize itself to one part, and hence by unilateral 
radiating pains, anaesthesia, and paresis. 

Meningitis has to be distinguished from muscular rheumatism, 
myelitis and tetanus. In muscular rheumatism of the back the pain is 



822 



SPECIAL DIAGNOSIS. 



local, and while increased by pressure and especially by motion, it is not 
accompanied by shooting pains in the trunk and limbs, nor by disturb- 
ances of sensation and motion ; moreover, fever is moderate or absent. 

In myelitis without accompanying meningitis local vertebral and root- 
pains are slight or absent entirely, and paralysis occurs early and is not 
accompanied by spasm. 

In tetanus initial fever is absent, the jaw muscles are early affected 
with tonic spasm (trismus), and general muscular spasms are easily 
provoked by touch or motion. 

The symptoms of chronic meningitis vary according to whether the 
dura (pachymeningitis) or the pia and arachnoid {leptomeningitis) are 
principally involved, and also according to the extent of irritation of 
the nerve roots and involvement of the cord. In leptomeningitis local 
pain in the back, stiffness of the muscles, and hyperesthesia of the skin 
are more marked than in pachymeningitis. Nevertheless root pains 
are present, and paresis of the legs from involvement of the cord some- 
times occurs early. On the other hand, in pachymeningitis local 
vertebral symptoms are subordinated to the root symptoms, and mus- 
cular atrophy may be marked. 

In general, the symptoms dependent upon irritation or structural 
alteration of the nerve roots are the most important for diagnostic 
purposes, and when taken in connection with the vertebral symptoms 
and their mode of onset are generally sufficient to differentiate the 
disease from the affections with which it is liable to be confounded. 

Meningeal Hemorrhage. This may be between the dura mater 
and the vertebrae (extra-meningeal), or within the dura (intra-menin- 
geal); the former is more common. The symptoms resemble those ot 
meningitis, but are more sudden and violent in their onset. Pain in 
the back is severest usually at a point corresponding to the seat oi 
hemorrhage. As in meningitis, there are pains shooting into the limbs, 
with numbness, tingling or formication, muscular spasms, and paresis 
or paraplegia ; when the hemorrhage is small there may be only pares- 
thesia and paresis of the extremities. If the hemorrhage be large there 
may be immediate paraplegia. As a rule paralysis does not become 
complete. 

The hemorrhage may be due to traumatism, to severe convulsions, 
violent exertion, or rupture of an aneurism. 

It needs to be distinguished from hemorrhage into the cord and from 
meningitis. In the former case vertebral pain is not so prominent a 
symptom as in meningeal hemorrhage, and is not usually so extensive. 
On the other hand paralysis is immediate, not gradual in onset, though 
it may be slight at first and then extend rapidly. Spasm is absent in 
hemorrhage into the cord, and recovery from the paralysis is more 
gradual. If hemorrhage involve both membranes and cord, of course 
the symptoms of both lesions will be seen together. 

The absence of fever helps to distinguish hemorrhage into the cord 
from meningeal hemorrhage. Moreover, the symptoms in the latter 
disease are of a more gradual onset. But a meningitis may be set up 
by the hemorrhage, iu which case its symptoms will follow those of the 
hemorrhage. 



DISEASES OF THE NERVOUS SYSTEM. 



823 



Hyperemia. Hypercemia of the spinal cord is indicated by a feel- 
ing of fulness, weight, or aching in the back, by paresthesia of various 
kinds, and perhaps by some increase in the reflexes, a feeling of heavi- 
ness in the limbs, and some motor weakness. The symptoms are re- 
lieved when the patient lies prone. Active congestion must occur from 
excessive stimulation of the cord and motor nerves — as in convulsions, 
excessive muscular exercise, or over-frequent coitus — because such con- 
ditions have produced hemorrhage ; but the symptoms merge into those 
of incipient inflammation so as practically to be inseparable from it. 

Anemia. Ancemia of the cord is difficult to distinguish with suffi- 
cient definiteness except in general anaemia, or anaemia from sudden 
hemorrhage. In these conditions there is paresis of muscles, which 
may result in complete paralysis from subsequent degeneration of nerve 
elements. Sensation is usually not disturbed. 

Compression of the Spinal Cord. 

Compression of the spinal cord is most frequently the result of caries 
or fracture of the spinal column ; but it occurs also in morbid growths, 
aneurism, and other conditions. 

Pain is a prominent symptom ; it is neuralgic in character, and may 
be felt in the upper or lower extremity or iu the trunk ; other symptoms 
are hyperesthesia of the skin, followed by anaesthesia in places, without 
cessation of the pain ("anaesthesia dolorosa"). There is more likely to 
be motor weakness and atrophy than spasm. The motor weakness is 
at first overshadowed by the shooting pains, and as a rule deepens 
gradually into paralysis. But if the compression gives rise to myelitis, 
paralysis occurs rapidly. The reflexes are exaggerated. Sensation may 
or may not be impaired below the level of the compression. The 
symptoms are very rarely unilateral, though frequently one limb is 
affected first and to a greater degree than the other. 

The diagnosis is based upon the existence of irritation of the nerve 
roots and cord, and upon the detection of some compressing cause. 
When the vertebrae are diseased, there is considerable local tenderness 
as well as pain, which is decidedly increased by movement. Additional 
diagnostic points are slow development, increase of reflexes, invasion of 
one side before and to a greater degree than the other. 

As to the cause of the compression, Gowers states that if the patient 
is in the first half of life, and inherits a tubercular tendency, caries is 
suggested. The absence of root symptoms is also in favor of caries, 
but their presence does not render caries less likely unless the pain is 
extremely severe and is greatly increased by movement. 

Recovery will depend for the most part upon the persistency or 
increase of the compression. If it be removed, or even if it cease to 
increase, recovery is often complete. 

Myelitis. 

Myelitis, or inflammation of the spinal cord, may be acute or chronic. 
It may involve the entire thickness of the cord through a short segment 
(transverse myelitis); it may involve continuously a large section of 



824 



SPECIAL DIAGNOSIS. 



the cord {diffuse myelitis) ; or scattered areas may be affected {dissemi- 
nated myelitis) ; or one small area may alone be the seat of inflamma- 
tion {focal myelitis) ; when the gray matter is wholly or chiefly involved 
it is called poliomyelitis. 

Acute Transverse Myelitis is characterized by the rapid develop- 
ment of paralytic symptoms, impairment or loss of sensation, a girdle 
sensation at the level of the lesion, either increase or loss of reflex 
action, more or less atrophy of the affected muscles, and paralysis of 
the sphincters. The onset of the disease may be preceded by fever, 
headache, delirium, or gastric derangement; by rheumatoid pains; by 
paresthesia in the limbs ; or it may be ushered in abruptly by a con- 
vulsion. Convulsions, however, are rare, except in children. Verte- 
bral pain is rarely marked and may be absent entirely. 

Retention of urine is a very significant and important early symptom. 
The paralytic phenomena begin by a feeling of weight and weariness in 
the limbs, possibly accompauied by numbness and tingling. If the 
patient be walking he will be obliged to sit down to rest, and attempt- 
ing to rise, he may find it impossible. More frequently the paraplegia 
develops more gradually and becomes complete only after the lapse 
of some days. In other cases after paresis has existed for several days 
paralysis supervenes somewhat suddenly. 

Paralysis of sensation may be complete or variously impaired. Sen- 
sibility to touch may be lost while pain is felt. A hypersesthetic zone 
usually exists immediately above the lesion, and its seat is detected by 
passing a hot sponge down the spine. When opposite the zone the 
sense of warmth becomes one of pain. The girdle sensation is felt at 
the same level. 

The condition of the reflexes and of the nutrition of the muscles 
depends largely upon the seat of the lesion. If the lumbar enlarge- 
ment is involved in the inflammation the reflexes are abolished and 
atrophy speedily follows. If above the lumbar enlargement, the reflexes 
may be lost temporarily, but are subsequently regained and become 
exaggerated, while atrophy to any considerable degree does not occur. 

The urine and fseces are at first retained, and subsequently are passed 
involuntarily. Trophic changes in the skin predispose to ulceration 
and bedsores. Severe cystitis is not uncommon. Fever is present 
during the progressive stage of the disease, but is usually slight — 99° to 
101°. 

The initial lesion may be the only one, or the inflammation may 
tend upward or downward ; or, again, after apparent convalescence, 
there may be a fresh outbreak. In cases that end in recovery sensation 
is regained in the course of a few weeks or months, and eventually 
motion also. Spastic paraplegia may be left as a result. 

Acute myelitis may result in death or in recovery, and the latter may 
be complete or incomplete. Death may occur early from interference 
with respiration, or occur later from the involvement of the medulla 
by disseminated myelitis, or be secondary to disease of the kidneys or 
of other organs, particularly to exhaustion or septicaemia from bedsores ; 
when recovery occurs the restoration to power is slow. 

Disseminated Myelitis is characterized usually by the consecutive 



DISEASES OF THE NERVOUS SYSTEM. 



825 



development of symptoms pointing to lesion of the cord at different 
levels. It requires for its exact diagnosis ability to differentiate the 
symptoms produced by various focal lesions. Gowers states that the 
onset of this form is often subacute, and that constitutional symptoms 
are often absent. 

" An inflammation which continues to extend after the first two or 
three days is certainly disseminated, and most subacute cases are of 
this variety, and so are those that are secondary to blood states. The 
distinction is important, because this form is far more grave than any 
other and more likely to cause death." 

Central Myelitis is the name given to inflammation of the gray 
matter surrounding the central canal of the cord. It is characterized 
by violence of onset and by a rapidly fatal course. There are complete 
paraplegia and complete loss of sensation iu the lower limbs; the 
sphincters are paralyzed and reflex action abolished. Moreover, the 
affected muscles atrophy with great rapidity. Fever is marked, and 
death usually occurs in a few days. 

Acute myelitis may arise from traumatism, from hemorrhage, or be 
secondary to meningitis. It may also arise from cold, particularly 
from lying upon the back on damp ground ; from over-stimulation of 
the cord by sexual excesses ; in the course of or during convalescence 
from the infectious fevers; and under the influence of gout, syphilis, 
and alcoholism. 

Chronic Myelitis. Chronic myelitis, called also diffuse myelitis, 
diffuse sclerosis, chronic transverse myelitis, presents symptoms differing 
from those of acute myelitis chiefly in their slow onset. Its essential 
characteristics are the impairment of motion and of sensation, pares- 
thesia aud sometimes dull pains in the legs, a decided girdle sensation, 
exaggeration of the reflexes, and usually not much atrophy. 

The patient finds that the legs are heavy, and that they become tired 
easily. He walks slowly, does not lift his feet clear of the ground, but 
is inclined to drag them. The muscles become rigid, and as they grow 
weaker the reflexes are exaggerated until a condition of spastic 
paraplegia is reached. Sometimes there is loss of coordinating power, 
but no true ataxia. Constipation and slowness aud difficulty in 
micturition indicate the impairment in expulsive power of the rectum 
and bladder. Sensation is not lost to the same extent as motion. 
There is often a constant dull pain in the back, and the affected limbs 
may be the seat of tingling, numbness, and formication. There is 
usually well-marked girdle sensation. 

The disease may be widely scattered, and hence almost every symp- 
tom of spinal involvement may be met with. 

If the gray matter is involved {chronic poliomyelitis) there are 
atrophy, anaesthesia, and paralysis. These develop with greater or less 
rapidity, sometimes involving the legs first and then the arms, and 
sometimes the arms first and then descending. 

Chronic myelitis usually runs a very chronic course. It may pro- 
gress steadily and uniformly, or at times grow worse rapidly ; but at 
any period the disease may be arrested and become stationary. Its 
duration is therefore extremely indefinite, varying from one to twenty 



826 



SPECIAL DIAGNOSIS. 



years. Spitzka states that the average duration is from six to fifteen 
years. 

Chronic myelitis is differentiated from hysterical paraplegia by the 
presence of degenerative reaction in the muscles, by the fact that in- 
continence of urine is more common in myelitis, while in hysterical 
paraplegia retention is the rule ; by the absence of pupillary phenomena 
in the latter ; and by the fact that anaesthesia, if present in hysteria, is 
less likely to correspond with the distribution of the motor paralysis. 
Moreover, the hysterical patient can overcome the paraplegia to a con- 
siderable degree by a strong effort of the will. 

From compression of the cord it is distinguished by absence of any 
obvious cause of pressure, such as injury or caries of the vertebrae, and 
absence of root-pains, which would iudicate that the process had begun 
outside the cord. 

From tumor of the cord it is distinguished by the comparative 
absence of root-pains. Both may involve one-half of the cord more than 
the other, but myelitis is more likely than tumor to present absolutely 
unilateral symptoms. 

From primary lateral sclerosis (spastic paraplegia) it is distinguished 
by the existence of both motor and sensory impairment, whereas in 
spastic paraplegia the symptoms are entirely motor. 

From progressive muscular atrophy it is distinguished by the 
atrophies of myelitis being irregularly distributed, while those of pro- 
gressive muscular atrophy are symmetrical. Moreover, in the former 
there are other cord symptoms and sensory disturbances. 

Pachymeningitis is distinguished principally by greater pain and by a 
more pronounced and extensive anaesthesia. Gowers says that if there 
are similar symptoms in both arms and legs, myelitis is far more probable 
thau pachymeningitis, since the chronic inflammation of the membranes 
is less extensive than that of the cord. 

Anterior Poliomyelitis. This disease is also called atrophic spinal 
paralysis, and infantile spinal paralysis, etc. Children up to the fifth 
year are most frequently attacked, and invasion is more common in 
summer than in winter. Its essential characteristics are suddenness of 
onset with complete paralysis, which speedily abates to a certain extent, 
leaving certain muscles or groups of muscles permanently paralyzed ; 
these waste rapidly and progressively, and lose their electrical con- 
tractility. Sensation is undisturbed, the sphincters remain unaffected, 
trophic disturbances of the skin are absent, and the intellect is not in- 
volved. The affected limbs are contractured. 

The onset of the disease may be marked by fever, which is usually 
moderate, by convulsions or delirium, by rheumatoid pains ; or it may 
appear without warning of any kind, either during the day, or be found 
in the morning after a quiet night. Fever, when it occurs, rarely pre- 
cedes the paralysis more than a day or two. Sometimes the disease 
develops during the course of, or during convalescence from, one of the 
specific fevers. The extent of the paralysis varies ; it may involve only 
one limb, or all four limbs and the trunk. If the child has been ill, or 
if the early symptoms have compelled the child to go to bed, paralysis 



DISEASES OF THE NERVOUS SYSTEM. 



827 



may be detected first when the child gets up, previous disability being 
attributed to general weakness or lack of energy. 

The paralysis attains its greatest extent rapidly, often in a few 
hours ; remains unchanged for from two to six weeks, and then begins to 
abate in the inverse order in which it begau. That is to say, if the 
arm was first affected and the leg last, the paralysis in the leg will begin 
to improve first. This order of improvement is characteristic, and led 
Barlow to call the disease " regressive paralysis." All the affected 
muscles do not recover. Those which remain permanently paralyzed 
waste rapidly and display degenerative reaction. 

The superficial reflexes are lost, but there is no loss of sensation, 
although paresthesia may be felt. The bones may cease to grow in the 
affected limb, which therefore becomes shortened relatively to its fellow. 
Contractures are a late result. 

Acute Ascending Paralysis. Acute ascending, or Landry's 
paralysis, is characterized by a rapid and progessive paralysis, beginning 
usually in the feet and extending upward, involving the muscles of the 
trunk, chest, arms, and neck ; swallowing and speech may be abolished. 
Sensation is practically unaffected, though there may be paresthesia 
and hyperesthesia of the skin. Reflex action may or may not be 
regained. 

The muscles are toneless and are neither atrophied nor changed in 
their electrical reactions. The disease is afebrile. Enlargement of the 
spleen has been noted in several cases. 

The course of the disease is usually rapidly fatal, most of the patients 
dying within a week ; but it may last several weeks, and recovery is not 
impossible. 

The cause of the disease is unknown, and no lesions have been found 
post-mortem. 

Diver's Paralysis. Diver's paralysis is generally a paraplegia ; 
it comes on in persons who have remained at a considerable depth below 
the surface for at least an hour. It is more apt to occur after the diver 
has returned to the air than when he is in the water. It usually comes on 
very rapidly, sensation as well as motion being lost, and the lower half 
of the body feeling numb and foreign to the patient. Recovery gen- 
erally occurs in from three to ten days, but it may be much slower 
than this, and may in rare cases be permanent. Death occurs occasion- 
ally. 

Hemorrhage into the Spinal Cord. 

Hemorrhage into the spinal cord, or hematomyelia, is extremely rare 
clinically. The symptoms produced are those already described as 
occurring in acute transverse myelitis, from which the essential point of 
difference is the great suddenness of onset. It may arise from injury, 
over-exertion, and sexual excess. 

The prognosis depends upon the size of the hemorrhage and upon its 
seat. 

It is better in proportion to the rapidity with which sensation is re- 
gained. Myelitis may, however, be a secondary result. 



828 



SPECIAL DIAGNOSIS. 



Degenerations of the Spinal Cord. 

1. Locomotor ataxia. 

2. Primary spastic paraplegia. 

3. Ataxic paraplegia. 

4. Chronic muscular atrophy. 

5. Arthritic muscular atrophy. 

6. Pseudo-hypertrophic muscular paralysis. 

7. Thomsen's disease. 

8. Tumors. 

9. Syringomyelia. 

Locomotor Ataxia. Locomotor ataxia, frequently also called tabes 
dorsalis, also posterior sclerosis, is a chronic degenerative disease of the 
spiual cord, involving the posterior columns and root fibres, and char- 
acterized by lightning pains, usually felt in the legs, by absence of 
knee-jerk, and by incoordination of movement without paralysis or 
muscular wasting. 

The lightning pains and loss of knee-jerk precede the incoordination, 
which very rarely is absent. 

Incoordination of movement is of gradual development. The patient 
usually first notices that at night he cannot walk without stumbling, 
though during the day he walks well enough. Or he may not have 
noticed any loss of coordination himself, but when examined by the 
physician it will be found that when asked to close his eyes and then 
walk, he staggers and would fall unless supported ; and that he is unable 
to maintain his equilibrium when standing with the feet close together, 
unless the eyes are at the same time open. The reason for this is that 
the muscular sense and sense of position are deficient, and without the 
guidance of vision the patient cannot tell where he is. By degrees 
incoordination becomes manifest, even when the eyes are open. The 
gait becomes, in time, characteristic ; the leg is thrown laterally and for- 
ward with a jerk, and then brought down suddenly and forcibly, the whole 
sole striking the ground. Finally, he may be unable to rise to his feet, 
as any attempt to rise, or contact of his feet with an object, produces 
spasmodic, pendulum-like motions. Incoordination may affect the arms 
also, but almost always after the legs have been affected. Ataxia may 
be developed on making attempts to write, or to button and unbutton 
the coat. The muscles retain their power, except in advanced cases, 
when there may be some weakness. 

Disturbances in sensation are very marked and are very rarely absent. 
Darting pains in the legs, called from their suddenness and severity 
"lightning" pains, are characteristic. They are paroxysmal, and while 
usually felt in the legs, may shoot into the arms, head, or other parts. 
The pains are not always lightning in character, but may be ordinary 
neuralgic or rheumatoid pains. Painful girdle sensations may be felt 
iu the trunk and limbs. Parsesthesise are frequently complained of and 
partial anaesthesia is common later in well-marked cases. The percep- 
tion of sensation may be considerably retarded. 

The cutaneous reflexes are usually lessened, but in the early stages 
may be greatly exaggerated. Loss of sexual power is the rule; it may 



DISEASES OF THE NERVOUS SYSTEM. 



829 



occur early in the disease, or be a sequel to abnormally increased 
passion. The deep reflexes, particularly the knee-jerk, are almost in- 
variably absent in the affected territory. 

The rectum and bladder are more often sluggish in action than para- 
lyzed. The eye symptoms are optic atrophy, paralysis of the ocular 
muscles, and the Argyll-Robertson pupil, i. e., a pupil which contracts 
to accommodation but not to light. 

A great variety of vasomotor and trophic symptoms may be present, 
such as oedemas, local sweatings, skin eruptions, atrophies, and joint 
changes. 

The name crisis is used in tabes to describe the paroxysmal derange- 
ments of the functions of various organs which occur in the disease. 
The most common are gastric crises, in which there is severe pain in the 
stomach followed by vomiting, which may or may not be attended by 
nausea. Any organ may be subject to corresponding crises; thus we 
have at times laryngeal, rectal, or vesical crises. 

The course of the disease is extremely chronic. Gowers says it is 
exceedingly common for the first stage — in which there is no alteration 
in gait, but loss of knee-jerk, pain, often Argyll -Robertsou pupil, and 
unsteadiness on standing with the feet together and the eyes shut — to last 
for from ten to twenty-five years. He does not think the disease shows 
a progressive tendency in more than half the cases in which it is recog- 
nized early and carefully treated. 

There is no general rule in the matter of progress. Often one symp- 
tom improves, and another appears or is aggravated. The disease itself 
is not fatal. Death may result from complications involving the 
kidneys and heart, or from some other nervous disease. As the primary 
cause of locomotor ataxia is in most cases syphilis, any other tertiary or 
secondary manifestation of syphilis may be found to coexist. 

Primary Spastic Paraplegia. Primary spastic paraplegia, or 
primary lateral sclerosis, is a chronic degenerative disease of the cord, 
probably involving the pyramidal tracts or their terminations in the 
gray matter. It is characterized by a gradually developed loss of 
motor power in the lower extremities, spasmodic contractions of the 
muscles, with exaggerated reflexes, absence of wasting, maintenance of 
sensation, involvement of the sphincters, and a very chronic course. 

The combination of rigidity with spasm makes the gait peculiar. 
In fully developed cases the patient cannot easily bring the foot for- 
ward ; it drags behind and the toe has a tendency to stick into the 
ground ; and as clonus is easily excited, there may be spasmodic con- 
tractions after the foot touches the ground. Sensation is, as a rule, 
maintained undisturbed, but parsesthesise may be present. 

The arms as well as the legs may be involved, or only one arm and 
the corresponding leg. The disease may also be congenital. This form 
is distinguished, according to Gowers, by the wide separation and 
irregular movement of the fingers on attempting to take hold of an 
object. From pseudo-hypertrophic paralysis it is distinguished by ex- 
aggeration of the patellar reflex, absence of wasting, and presence of 
clasp-knife rigidity. "The impairment of locomotion gradually lessens 
in birth-palsy, while it increases in pseudo-hypertrophic paralysis." 



830 



SPECIAL DIAGNOSIS. 



The prospect of arrest of the disease and improvement of the 
paralysis is better in the infantile form than in adults, but even in them 
it may occur. As a rule, however, arrest of the disease is as much as 
can be hoped for. It is not fatal in its tendency. 

The disease is distinguished from locomotor ataxia by the exaggera- 
tion of reflexes instead of their abolition, and by the absence of eye 
symptoms, lightning pains, and painful crises. Other portions of the 
cord are at times involved and give rise to disturbances of sensation or 
to muscular atrophy. Hysterical paralysis is excluded by the presence 
of spasmodic rigidity, with excessive knee-jerk and ankle clonus. 

Ataxic Paraplegia. Ataxic paraplegia, or lateral and posterior 
sclerosis, presents characteristics of both locomotor ataxia and para- 
plegia. The prominent symptoms are the very gradual development 
of motor weakness and of loss of coordinating power. The weakness 
is first noticed in walking, and the loss of coordination at night or 
when the eyes are closed. The flexor tendons are more affected than 
the extensors. The weakness and lack of coordination increase gradu- 
ally until the gait becomes feeble and tottering and finally impossible 
without constant support. Up to this point the disease resembles loco- 
motor ataxia, but it is distinguished from it by the absence of light- 
ning pains and the preservation of the muscle reflexes — indeed, the 
patellar reflex is much exaggerated, and ankle clonus is usually present. 
There may be dull pains in the back and legs. The arms may or may 
not be involved. The muscles do not atrophy. Eye symptoms are 
usually, not always, absent. There is some loss of power over bladder 
and rectum, but it does not amount to paralysis, and not often to con- 
siderable paresis. 

The sexual power is lost, but it may be regained for a time. The 
progress of the disease is toward a condition of spastic paraplegia, the 
gait in which has already been described, the loss of coordination 
becoming less marked as the paralysis increases. Cerebral symptoms, 
beyond loss of memory and occasionally defect in speech, are absent. 

The disease runs a very chronic course, and is not fatal in itself. 
Death, as in other degeneration, results from complications, particularly 
kidney disease and bedsores. The disease is distinguished from loco- 
motor ataxia by the presence of the patellar tendon reflex ; from spastic 
paraplegia by the presence of incoordination ; and from chronic myelitis 
by the absence of girdle sensation. 

Hereditary Ataxia. Hereditary ataxia, Friedreich's disease, or 
hereditary ataxic paraplegia, is a special form of ataxia which differs in 
the following important particulars from the ordinary form. It is 
hereditary ; it develops most frequently in childhood and at the age of 
puberty; it attacks males and females with about equal frequency; 
lightning pains are usually absent; and there is greater tendency for 
the disease to involve the arms and to affect speech. 

The disease develops gradually. Incoordination, first of the legs 
and then of the arms, is the most obtrusive symptom. The muscle 
reflexes are abolished. Nystagmus is the most constant ocular symp- 
tom. The effect upon sensation is variable; sometimes it is impaired 
and at others it is entirely normal. 



DISEASES OF THE NERVOUS SYSTEM. 



831 



The duration of the disease is. very chronic — from ten to thirty years. 
Gowers says the only guide to individual prognosis is the observed rate 
of progress. 

Progressive Muscular Atrophy. Progressive muscular atrophy, 
wasting palsy, chronic poliomyelitis, or amyotrophic lateral sclerosis, is 
due to a combined degeneration of the multipolar cells in the gray 
matter of the anterior cornua, and of the pyramidal tracts. 

The disease usually attacks an arm first, and either the hand or 
shoulder muscles; and next in frequency, a leg. Preceding any notice- 
able weakness of the affected member there is sometimes aching and an 
unaccustomed feeling of weariness after its use. Sometimes, however, 
wasting is the first thing that attracts attention, particularly if the 
hand is affected first, for here wasting of the interossei makes a char- 
acteristic appearance. The corresponding leg is not usually noticeably 
affected during the first six months. The atrophy is almost always 
steadily progressive, involving the muscles of the chest and neck, in 
addition to those of the legs and arms. Loss of power accompanies 
the atrophy. As a rule this loss is most marked in the arms, while 
the legs, before wasting becomes marked, are in the condition described 
under spastic paraplegia. The muscle bundles often exhibit fibrillary 
twitchings. The atrophied muscles give characteristic degenerative 
reactions. 

Respiration is much embarrassed from involvement of the diaphragm 
and external respiratory muscles. The face generally escapes, but 
speech is involved from extension of the disease to the medulla, and 
glosso-labial paralysis is simulated. 

Sensory symptoms rarely amount to more than dull pains, except 
when there is an associated meningitis. The sphincters are not usually 
involved, but sexual power is generally lost. In advanced cases the 
affected limbs, especially the upper extremity, are wasted so that they 
appear like skin stretched over the bones. 

The average duration of the disease is said to be about three years, 
but the progress may be more or less rapid than this in individual 
cases. It rarely becomes arrested. Gowers says that wasting which 
has existed for six months will probably persist unchanged. The 
chief dangers to life are pulmonary complications and bulbar paralysis. 

Pseudo-Hypertrophic Muscular Paralysis. Pseudo-hyper- 
trophic muscular paralysis is a primary disease of the muscles, consist- 
ing of an overgrowth of connective tissue and subsequent atrophy of 
the muscle. The disease occurs almost always in childhood, sometimes 
being noticed as soon as the child begins to walk, and it may be con 
genital. The calf muscles are first involved, and hence the child is 
apt to be slow in learning to walk. The gastrocnemii are apparently 
much enlarged, though this enlargement may be concealed in a fat 
child. It stumbles and falls in attempting to run, and is unable to 
raise itself on tiptoe. The calf muscle is at first much harder than 
normal, and subsequently becomes softened through increase of lipom- 
atous tissue. The legs may be recognized as weak for months or 
even years before characteristic changes are detected in the muscles ; 
but usually the apparent hypertrophy can be noticed within a few 



832 



SPECIAL DIAGNOSIS. 



weeks or months after weakness has become manifest. Gradually 
other muscles become affected, the infra-spinatus most frequently. 
Gowers attaches great diagnostic importance to the coexistence of en- 
largement of the infra-spinatus and wasting of the latissimus and lower 
part of the pectoralis. As atrophy and accompanying weakness 
increase, change of position is accomplished with more and more diffi- 
culty ; the feet are spread wide apart, and the gait is oscillating (''duck- 
like"). If prone upon the ground, the child raises himself first upon 
his hands aud knees, then extends the knees and rests upon toes and 
hands, then places one hand upon a knee with the other remaining 
upon the ground, aud then pushes himself upright from this position. 

Contractions and deformities are a later stage, the most important of 
which are club-foot aud curvature of the spiue. Sensation and the 
functions of the bowel and bladder are unaffected. The course of the 
disease is progressive, but very slow. Gowers states that severe pul- 
monary disease generally ends life some time between twelve and twenty. 
Few patients reach the age of forty. The course of the disease is slower 
in girls than in boys. 

Simple Idiopathic Muscular Atrophy. Simple idiopathic 
muscular atrophy differs from the pseudo-hypertrophic form in that it 
occurs in families, that it presents no apparent hypertrophy of muscles, 
and that the palsy involves the face, occurs at a later period, and affects 
females equally with males. 

The disease develops very gradually and affects persons with an 
hereditary tendency to the disease. It occurs most frequently between 
the fifteenth and thirtieth year, but may appear in infancy and after 
middle life. Atrophy and loss of power go hand-in-hand, appearing 
first usually in the upper arms, legs, or face. Uulike progressive 
muscular atrophy the deltoids are not usually involved, the disease 
attacking the biceps, triceps, long supinator, and external muscles of 
respiration. Eventually both sides are affected, though the disease 
frequently begins on one side. The facial expression changes ; the 
lower lip juts forward, the lips are held apart, and the labio-uasal 
furrow is obliterated, giving the face a dull and wondering expression. 

In the lower limbs some of the thigh muscles are affected, but not the 
calf muscles. The diaphragm may also be involved. The muscles do 
not show degenerative reactions, fibrillary twitching is almost always 
absent, sensation is undisturbed, the functions of bladder and rectum 
remain unaffected, aud trophic and vasomotor symptoms are absent. 

There is no uniformity in the rate of progress of the disease; it may 
reach its extreme only at the end of a very long life, or in a decade. 
The disease has no direct tendency to kill. Gowers says that in the 
cases of most severe degree and rapid course the patient has usually died 
of phthisis. 

Thomsen's Disease. Thomseu's disease is a rare congenital and 
hereditary affection, characterized by tonic spasm of the muscles when 
an attempt is made to put them in motiou after a period of rest. If the 
attempt is persisted in, the spasm gradually lessens until free use of the 
parts cau be obtained. The muscles do not waste and do not exhibit 
degenerative reaction. 



DISEASES OF THE NERVOUS SYSTEM. 



833 



Tumors of the Spinal Cord. 

Tumors of the spinal cord may be syphilitic, cancerous, or tubercular. 
The prominent symptoms of tumor are pain and gradually developing 
paralysis. The character of the pain is that already described as root 
pain — darting and shooting ; it is paroxysmal, very severe, sometimes 
agonizing, making life a burden. Local tenderness is not marked, 
and may be entirely absent. The pains often begin on one side and 
finally affect both sides. Paresthesias and anaesthesia are also present. 
Muscular spasm is a further evidence of irritation of nerve roots ; other 
symptoms are girdle sensations, paralysis, atrophy, and contractures. 
The paralysis, like the root pains, is often at first unilateral, but usually 
becomes bilateral in course of time. It begins first as a paresis and 
only gradually deepens into paralysis. 

The superficial and deep reflexes are sometimes decidedly increased. 
There may be a difference in temperature upon the two sides. 

The diagnosis of the seat of the tumor must be made from noting the 
level at which the cord functions are disturbed. Tumors of the cord, 
as distinguished from those of the membranes pressing upon or extending 
into the cord, are characterized by a relative prominence of paralysis 
and absence of root symptoms. It should be remembered that a 
secondary myelitis may be produced. If the lumbar enlargement is 
involved, or the cauda, reflex action is abolished ; whereas if situated 
in the dorsal region or still higher up ? reflex action is exaggerated ; 
again, in tumors of the lumbar enlargement and cauda the legs atrophy. 
Tumors of the cervical region cause pain in the arms, and often atrophy, 
while the legs show excessive reflex action. There may also be inter- 
ference with respiration. 

Syringomyelia. 

Syringomyelia is a chronic affection of the spinal cord, of congenital 
origin, characterized pathologically by the presence of cavities. During 
life it may give rise to no symptoms, and therefore be unsuspected. 
"When symptoms do occur they consist of paresis, anaesthesia, and 
atrophy. Atrophy and anaesthesia affect the hands principally, and 
paresis the legs. The functions of the bladder and rectum are often 
deranged, and trophic changes in the skin may occur. The pressure 
sense may be lost in the arms. The duration of the disease from the 
time symptoms occur is from two to three years, and the result fatal. 

Diseases of the Brain. Pachymeningitis. 

Inflammation of the dura mater usually develops secondarily to 
disease of adjacent structures or to injury ; its symptoms are to be 
picked out from those of the primary condition. The prominent 
symptoms are headache, fever, delirium, and perhaps convulsions. 
Fever is not a constant symptom. If pressure is exerted upon 
the cortical motor area there may be paralysis of the opposite limbs. 

53 



834 



SPECIAL DIAGNOSIS. 



Leptomeningitis. 

Inflammation of the pia and arachnoid may be acute or chronic; 
may be simple; tubercular, syphilitic, or epidemic (see Cerebro-spinal 
Fever) ; it may be confined to the cortex or base, or be general. 

1. Acute Meningitis is characterized by the more or less sudden 
onset of headache, vomiting, delirium, and convulsions, accompanied by 
stiffness of certain muscles, especially of the muscles of the back of 
the neck, and later by paralysis and coma. 

Headache is the most prominent symptom. It is most frequently 
frontal, but rarely may be general ; is usually intense, and in paroxysms 
becomes maddening, causing the patient to shriek with the pain. It is 
aggravated by light and by sound or other vibration. Rarely, headache 
is absent ; when this is the case, however, it is most frequently in the 
meningitis secondary to septic or blood diseases. 

Vomiting is sudden and explosive, without antecedent or subsequent 
nausea or any local cause except the presence of food. 

Delirium is usually active in type, and may be mild or almost 
maniacal. It is not often continuous, but is broken by lucid intervals. 
When coma appears it follows delirium. 

Rigidity of the muscles of the back of the neck, in marked cases 
accompanied with retraction of the head, is an important symptom. 
Convulsions when they occur are general. They are more likely to 
occur in children than in adults. They may also be partial or uni- 
lateral, and so may paralyses. Cutaneous hyperesthesia is not very 
uncommon. Neuritis of the optic nerve, according to Gowers, is a 
common symptom in meningitis of the base, but is rare when the 
inflammation is confined to the convexity. The most constant and 
important eye symptoms are strabismus and inequality of the pupils. 
The facial nerve may be affected, especially in meningitis of the base. 

The range of temperature is far from uniform. Usually there is 
moderate fever from the start. Sometimes, especially in purulent cases, 
the fever is high and remains so until the patient's death. In fatal 
cases the temperature may either rise or fall on the approach of death, 
and in rare cases it may remain normal throughout. The pulse is not 
characteristic. 

The disease lasts from one or two days to two or three weeks. 

The symptoms vary somewhat according to the character of the 
inflammation. In simple meningitis the fever is more marked, optic 
neuritis is more common, and the duration is longer. Recovery may 
ensue. 

Tubercular Meningitis is preceded by deterioration of the general 
health, emaciation, slight evening fever, peevishness, and sometimes 
distinct evidence of tubercle elsewhere, particularly in the lungs. 
Headache and apparently causeless vomiting are important symptoms ; 
they may appear first at the onset of the disease, or may precede it by 
a short time. Other early symptoms are constipation, nightmare, 
irregular pulse, and cerebral hyperesthesia, as the result of which 
light becomes painful, and slight sounds are disturbing. Loss of 
flesh continues, there is moderate fever, the abdomen becomes retracted, 



DISEASES OF THE NERVOUS SYSTEM. 



835 



the child loses strength, becomes apathetic, lying with its eyes partly 
open. It may be roused to temporary interest in its accustomed play- 
things, but soon turns from them in anger or disgust. Bright-red spots 
or streaks of hypersemia may appear and disappear rapidly from the 
face. If the thumb-nail be pressed upon the skin and drawn across it, 
a red streak follows — the tdche eerebrale. 

The child's sleep is disturbed by dreams, and it utters a peculiar 
piercing cry, the " hydrocephalic cry." 

There may be some rigidity of the muscles of the back of the neck. 
Gowers lays particular stress upon the occurrence of aphasia. The 
eye symptoms are strabismus, irregularity of pupils, and optic neuritis. 

Delirium and convulsions may occur early, but usually not until the 
second week. Local convulsions and corresponding palsies are common, 
but the palsy may be transient. Death may occur in convulsion, or 
more commonly in coma. 

The temperature range is not constant, and often fluctuates consider- 
ably within short intervals. The pulse is often frequent at first, then 
becomes slow and irregular, and finally very frequent. The respiration 
is irregular and cerebral in type toward the close of the disease. 

The duration of the disease is usually from one to three weeks, but it 
may be prolonged to twice that time. The prognosis is not necessarily 
fatal, but most patients die. The prognosis is graver when convul- 
sions or coma appear early, and is better the longer coma is deferred. 

Meningitis is to be distinguished from general febrile diseases with 
cerebral symptoms. Headache is common in the latter, but it is rarely 
so intense as in meningitis, unless there be at the same time high fever. 
Delirium is also common in both, but it succeeds the headache in febrile 
diseases, whereas in meningitis both symptoms persist together. Con- 
vulsions may occur at the onset of the exanthemata and pneumonia, 
but in meningitis they are a later symptom. Eye symptoms are absent 
in general febrile diseases. The best safeguard against a mistake in 
diagnosis is to examine every organ carefully before concluding that the 
mischief is in the brain membranes ; particularly the lungs should be 
examined for a pneumonia, and the spleen and bowels for signs of 
typhoid fever. Tubercular meningitis is generally secondary, but it is 
not often possible to detect the primary focus. 

Tubercular meningitis is distinguished from the simple form by the 
occurrence of premonitory symptoms of failing health in a child dis- 
posed by heredity to tuberculosis, or affected by an antecedent tubercu- 
losis of bone, gland, or lung. It is further distinguished by the absence 
of other cause of meningitis, particularly traumatism, suppurative 
disease of the middle ear, infectious disease, such as erysipelas, or 
septicaemia. Moreover, the individual symptoms are important : tubercu- 
lar meningitis is generally basilar ; hence apparently causeless vomiting, 
strabismus, irregularity of pupils, and optic neuritis are very significant 
symptoms. The pulse in tubercular meningitis is often at first frequent, 
then becomes slow — 40 to 60 — and irregular and intermittent in the first 
stage, subsequently becoming frequent and irregular, and finally very 
frequent, but regular. The respiration is irregular and sighing and 
may be Cheyne-Stokes. The temperature also has a lower range and is 



836 



SPECIAL DIAGNOSIS. 



more fluctuating than in simple meningitis. Gowers says that tubercular 
meningitis is one of the most common causes of aphasia in children, 
and that it is sometimes an early symptom. Aphasia, however, is 
difficult to detect in children of the age at which tubercular meningitis 
is most common. On the whole, the disease is more liable to be 
suspected when it does not exist than to be overlooked when present. 

In adults tubercular meningitis is rare and is always secondary, gen- 
erally to disease of the lungs. It is, therefore, a late manifestation of 
the disease, except in the cases in which there is a general miliary 
tuberculosis. 

Chronic Meningitis. Chronic meningitis is usually alcoholic or 
syphilitic, but it may be the result of sunstroke. The alcoholic form 
involves principally the convexity, and is characterized by headache, 
some loss of intellectual power, perhaps irritability of temper; there 
may also be occasional delirium and some optic neuritis. 

In the syphilitic form the meningitis is more likely to be local, and 
usually extends from the seat of a gumma. The symptoms, therefore, 
are apt to be focal. Gowers says that it is highly probable that focal 
inflammation in adults is always syphilitic in nature, the traumatic form 
of course excepted. 

The purulent form of acute meningitis most frequently affects the 
membranes of the convexity. It is characterized by high fever, with 
or without rigors, intense headache, vomiting, motor symptoms, possi- 
bly amounting to convulsions, and coma. 

It may arise from mastoid disease, from injury, or be part of a general 
septic process. Its course is usually rapidly fatal. 

Diagnosis. Meningitis is simulated by brain tumor. Loss of motor 
power in limbs indicates tumor rather than meningitis. Gowers says 
that if after the first two weeks from the commencement an optic neur- 
itis continues to increase and the patient does not become comatose, 
the diagnosis of tumor is almost certain. 

The most important symptom in differential diagnosis of meningitis 
from hysteria is increased temperature. When strabismus is present in 
hysteria it is convergent, never divergent. Gowers asserts that diver- 
gent strabismus or irregularity of pupil is certain evidence of organic 
disease, and as much so if it is transient as if it is permanent. In hys- 
teria, also, there may be retention of urine, but never incontinence. 

Cerebral Anaemia. 

Cerebral ansemia may be a part of the general ansemia which char- 
acterizes chlorosis, leucocythsemia, and many other affections; or it 
may result from hemorrhage or other exhausting discharge. In other 
cases it is local, resulting from a deficient supply of blood to the brain. 
Such ansemia occurs in arterio-sclerosis, in aortic valvular diseases, and 
in aneurism of the aorta and its cervical branches. 

If ansemia is suddenly developed, as from hemorrhage or a sudden 
assumption of the erect posture by a person with feeble circulation, the 
phenomena are those of faintness, ringing in the ears, dizziness, partial 
or complete blindness, general muscular relaxation, nausea, frequent, 



DISEASES OF THE NERVOUS SYSTEM. 



837 



feeble pulse, and shallow sighing respiration. The skin may become 
cold and be bathed in perspiration. The symptoms are aggravated by 
the erect posture. 

When anaemia develops gradually the symptoms are less intense. 
Intellection is performed with slowness and difficulty, slight effort 
causes weariness and headache, and the patient is drowsy. Sight and 
hearing may be defective, and muscse volitantes and tinnitus are com- 
mon causes of complaint. There is usually some muscular weakness. 

The diagnosis is not difficult. 

Hypersemia of the Brain. 

Hyperemia of the brain may be active or passive. 

The diagnosis of active congestion is more liable to be suspected when 
it is not present than overlooked when present. The most trustworthy 
symptoms, according to Gowers, are the paroxysmal recurrence of head- 
ache, delirium, and sometimes fever, preceded by throbbing of the 
vessels and reddening of the face. The probability of active conges- 
tion is increased if the symptoms are relieved by nose-bleed or vene- 
section. 

The diagnosis of passive congestion is based upon signs of a plethoric 
habit, such as florid complexion, turgid vessels, associated with a dull, 
more or less persisteut headache, which is aggravated by stooping, by 
coughing, constipation, or recumbent posture. Other symptoms are 
flashes of light before the eyes, slight dizziness, sluggish intellect with 
drowsiness, and some hyperesthesia of the extremities. Slight convul- 
sions sometimes occur. Passive congestion occurs in conditions which 
retard the escape of blood from the brain. 

Cerebral Hemorrhage. (Apoplexy.) 

Cerebral hemorrhage — that is to say, hemorrhage into the brain sub- 
stance — is caused, apart from traumatism, by the rupture of a bloodvessel 
the walls of which have been weakened by disease and have become the 
seat of minute, or miliary, aneurisms. 

The liability to it increases very markedly after the fortieth year. 
The symptoms differ considerably according to the extent of the hemor- 
rhage and its seat ; but the most frequent and prominent are sudden 
onset with loss of consciousness, convulsions, and coma, and, if recovery 
result, hemiplegia on the side opposite to the lesion. 

Premonitory symptoms are present in a few cases. These may be 
those of cerebral congestion (q. v.) or consist of vertigo, change of 
temper, or vomiting. In some cases an unusual sense of well -being 
has preceded an attack. It is probable that these symptoms are really 
due to minute hemorrhages. The onset may be very abrupt, the patient 
falling unconscious as though struck upon the head. More frequently 
the loss of consciousness, while sudden, is preceded by headache, giddi- 
ness, faintness, nausea, or difficulty in articulation. If the seizure has 
occurred after a hearty meal the patient usually vomits freely and then 
becomes unconscious, with conjugate deviation of the pupils, the face 



838 



SPECIAL DIAGNOSIS. 



drawn to one side, the cheeks flapping with stertorous respiration, the 
lips covered with froth, and the arms and legs upon the affected side 
alternately convulsed and rigid, and relaxed. 

If the attack comes on when the patient is standing, a weakness in 
one leg may cause him to fall or sit down, unconsciousness soon de- 
veloping. 

The degree in which consciousness is affected varies with the severity 
of the case. Usually it is completely lost, but it may be soon regained. 
Convulsions are most frequent when the hemorrhage is cortical. The 
pulse is usually slow and full, but it may be small, hard, and frequent. 
The respiration is stertorous, and may be Cheyne- Stokes. When 
convulsions are present they usually begin by twitching of the eyelids 
and eyebrows, rotation of the head and eyes by successive small move- 
ments to one side, usually the side of the brain lesion, and then the 
convulsion exteuds to the arm and leg and may become general. If 
consciousness is not completely lost the hemiplegia becomes very con- 
spicuous ; or if the seizure has occurred during sleep the patient may 
himself first become aware of it by the existence of hemiplegia when 
he attempts to get out of bed. When unconsciousness is profound 
(coma), urine and faeces may be passed unconsciously. In some cases 
there is an apparently mild seizure with rapid return of consciousness 
and power, except, perhaps, of speech, but in a few days the symptoms 
become worse and the patient dies comatose. The name ingravescent 
apoplexy has been applied to such cases. 

If consciousness is regained and the patient recover, the symptoms 
are then those of palsy. This is most complete at first. It may be 
recovered from entirely, but usually recovery is only partial. Its 
extent and distribution depend upon the seat of the lesion. It is 
almost always unilateral. 

The seat of the hemorrhage can be judged with tolerable accuracy. 
The most common seat is in the neighborhood of the corpus striatum 
and internal capsule, hence the frequency of hemiplegia. Cortical 
hemorrhage is rare. It is characterized by convulsions, which are 
local, and the resulting palsy may affect only a leg or an arm. A large 
hemorrhage into the pons causes deep coma, general paralysis, convul- 
sions which are usually general, but sometimes involving only the 
legs. The pupils are contracted, there may be general anaesthesia, vom- 
iting is common, and often high temperature. Death often occurs 
early. Hemorrhage into the optic thalamus causes a decided rise in 
temperature, but the palsy is slight. 

Hemorrhage into the medulla causes death speedily without the 
occurrence of convulsions but with high temperature. 

Hemorrhage into the cerebellum may or may not cause paralysis, 
and when it does the paralysis may be on the same side or on the side 
opposite to the lesion. It is attended by loss of consciousness and 
repeated vomiting, but vision is not affected. 

Hemorrhage into the ventricles is marked by profound loss of con- 
sciousness, with conjugate deviation of the head and eyes. There may 
be temporary improvement, followed by complete coma with or without 
convulsions. 



DISEASES OF THE NERVOUS SYSTEM. 



839 



Meningeal hemorrhage is usually of traumatic origin. If the blood 
is poured out suddenly the symptoms are those of severe apoplexy, 
with rapid development of coma. If the escape of blood is more 
gradual there is often a period during which the patient is able to walk 
about ; drowsiness then comes on, and deepens into coma. Less com- 
monly there are convulsions, and sometimes delirium. 

Diagnosis. The coma of apoplexy is distinguished from that of 
alcoholism by the presence of a drawn face and of more profound un- 
consciousness. Frequently the alcoholic can be roused sufficiently to 
grunt his disapproval or to turn over. The fumes of ammonia are 
said to rouse him. The temperature in alcoholic coma is depressed. 
The absence of convulsious is in favor of alcoholism. The respiration 
in the latter is quieter, and is not attended by frothing at the mouth 
or flapping of the cheeks. Mistakes are most likely to occur when no 
history of the patient's previous condition or of the mode of onset of 
the coma can be obtained. The odor of alcohol upon the breath is of 
value if the patient is known to be intemperate and if no one has 
administered alcohol subsequently to the coma. Incontinence of urine 
or of faeces is against alcoholism, and so is a bitten tongue. 

Apoplexy is distinguished from uroemia by its sudden onset and com- 
parative or complete absence of premonitory symptoms. In uraemia 
the patient has generally suffered from headache and morning nausea, 
which may be called by him " bilious attacks." The pulse is often of 
markedly high tension, and the second aortic sound is accentuated. In 
other cases there will be found oedema of the eyelids, a pale, waxy, 
bloated face, sometimes dropsy, and failure of vision. Marked drowsi- 
ness often immediately precedes an attack, and it is frequently accom- 
panied by cramps and twitching of the muscles. The coma of uraemia 
is accompanied by stertorous respiration and frothing at the mouth ; 
but the cheeks do not flap during respiration, and the face is not drawn 
as in apoplexy. The convulsions of apoplexy are more apt to be uni- 
lateral than those of uraemia, which are epileptic in type. They are 
often accompanied in apoplexy by conjugate deviation of head and 
eyes, but not in uraemia. Moreover, in apoplexy the skin is moist and 
warm, whereas in uraemia it is cool and dry and harsh. The tempera- 
ture in apoplexy may be elevated at first, and then depressed ; or it 
may continue to rise. In uraemia it is depressed. The condition of the 
urine is important in diagnosis, but it is not an infallible guide. A 
scanty, reddish, opaque urine, containing a large amount of blood and 
albumin, certainly points to uraemia; but apoplexy often occurs in a 
person of unsound kidneys, and its onset is frequently attended with 
the appearance of considerable albumin and of casts in the urine. 

Cerebral hemorrhage is to be distinguished from softening, the result 
of embolism, by the age of the patient, the presence or absence of a 
cause of embolism, such as valvular heart disease and syphilis, and the 
intensity of the symptoms. Embolism is more frequent in those under 
forty ; cerebral hemorrhage in those over forty. Intensity of apoplectic 
symptoms and persistent palsy are in favor of hemorrhage. When, 
however, the patient is past middle life the probability of softening 
does not diminish, and the diagnosis from hemorrhage must be made 



840 



SPECIAL DIAGNOSIS. 



by the symptoms and the condition of the patient. A high-tension 
pulse, hypertrophy of the left ventricle, and atheroma of the arteries of 
the limbs are in favor of hemorrhage ; on the other hand, a weak heart 
and feeble pulse favor softening. If the attack comes on after much 
excitement or strong muscular effort, it is in favor of hemorrhage. 

Premonitory symptoms, such as singing in the ears or paresthesia of 
one side are in favor of softening. Profound coma and violent convul- 
sions are probably from hemorrhage. 

Cerebral thrombosis is characterized by more gradual onset, shorter 
duration of paralysis, and other symptoms, and by more complete 
recovery. 

Thrombosis of the Superior Longitudinal Sinus. 

This occurs most frequently in children ; it may arise spontaneously 
in the course of acute diseases producing great prostration, especially 
entero-colitis. It results also, and more frequently, from inflammatory 
disease of the brain membranes or bone adjacent to the sinus, and ex- 
tension of the inflammation to the walls of the sinus. The symptoms 
are the gradual development of coma with convulsions, which may be 
general or unilateral. Headache, stabismus, and more or less rigidity 
of the limbs are common. Adults are more likely to be affected with 
delirium than with convulsions. Epistaxis may occur, and sometimes 
there is oedema with distended veins upon the scalp and forehead. 

The result is fatal in nearly all cases, but recovery is possible in 
spontaneous thrombosis. 

Infantile Hemiplegia. 

Infantile hemiplegia is an acute cerebral palsy occurring during the 
first five years of life ; it is either primary or secondary to acute dis- 
eases, particularly scarlet fever and measles. The onset of the disease 
may be marked by vomiting and convulsions, by drowsiness or coma, 
or the child may wake up in the morning with well-marked hemiplegia. 
In other cases a series of convulsions precedes the appearance of the 
palsy, and in still other cases the onset is marked by fever. The 
initial convulsions may be general, but more frequently they are 
unilateral ; when the left hemisphere is the seat of the lesion aphasia may 
be a symptom, and it is one of the slowest to disappear. The duration 
of the palsy is variable ; sometimes recovery is very prompt, occurring 
in a few days ; in other cases several months may elapse ; and in still 
others the paralysis may be permanent. It is always most intense and 
widespread at first, and then slowly disappears, the leg usually showing 
its effect longest. The palsy, as indicated by the name of the disease, is 
a hemiplegia ; in rare cases it is bilateral, due to a bilateral brain lesion. 
The affected limbs are at first limp and flaccid ; as power returns con- 
tractures begin, and eventually there may be some spasm, with or with- 
out clonic movements. The portions permanently paralyzed become, 
as the opposite side grows, shortened and somewhat wasted. Sensation 
is unimpaired. The mind is usually defective when palsy is permanent, 



DISEASES OF THE NERVOUS SYSTEM. 



841 



and idiocy and epilepsy are not infrequent sequences. The prognosis is 
good as regards life, but guarded as to the degree and duration of sub- 
sequent paralysis. Repeated convulsions render the prognosis grave. 
The rapidity with which consciousness is regained and the palsy begins 
to disappear is an index of the rapidity and degree of final recovery. 

Acute Softening". 

Acute softening of the brain is the result of embolism or thrombosis. 
The most common cause of embolism is a recent endocarditis with 
vegetations upon the valves. Thrombosis occurs in atheroma and in 
syphilitic inflammation of the cerebral arteries. It may also occur in 
general diseases, acute or chronic, which produce systemic weakness or 
weakness of the heart. 

The symptoms resemble more or less closely those of cerebral hemor- 
rhage. 

Embolism is to be distinguished by the age of the patient ; it is most 
common from adolescence to middle life ; whereas hemorrhage is more 
common after middle life. The onset is sudden and apoplectic in 
character. It is marked by coma and convulsions, but loss of con- 
sciousness is not usually so profound or of so long duration as in 
hemorrhage. This depends, however, somewhat upon the size of the 
vessel plugged. 

Thrombosis differs from both hemorrhage and embolism in being 
more gradual in onset. Premonitory symptoms, consisting of headache, 
dizziness, and paresthesia, are common. Consciousness may or may 
not be lost, depending upon the size of the occluded vessel and conse- 
quent area of softening. Delirium may follow the primary loss of con- 
sciousness, particularly in atheromatous softening. A secondary rise of 
temperature is more common in softening than in hemorrhage, and it 
may amount to hyperpyrexia. 

Aphasia, monoplegia, and recurring convulsions are, according to 
Gowers, more common in softening than in hemorrhage ; and in the 
subsequent chronic stage disorders of movement, mental failure, and 
emotional mobility are also somewhat more common in softening. An 
entire absence of focal symptoms is rather more common in softening. 

Abscess of the Brain. 

Abscess of the brain is most frequently the result of chronic suppura- 
tive otitis media ; and in such cases the symptoms of mastoid disease 
usually precede it. It may be the result also of injury or disease of 
the cranial bones, or be part of a septic process. It is most common in 
male adults between the tenth and thirtieth years. 

The most important consideration in diagnosis is the existence or 
antecedence of a cause of abscess in association with inflammatory cere- 
bral symptoms. 

The symptoms of brain abscess depend upon the character of the pus 
and its seat ; in some cases, particularly when the cause is traumatic, the 
symptoms are inflammatory and the progress of the case is rapidly to a 



842 



SPECIAL DIAGNOSIS. 



fatal issue in a few weeks ; in others, after a period of indefinite cerebral 
symptoms, the abscess becomes latent ; and in still other cases, particu- 
larly when there is a general disease, the cerebral mischief may be ob- 
scured. 

The symptoms in abscess which runs a rapid course are those of 
meningitis, rarely associated with focal symptoms. In the early stage 
delirium, convulsions, and coma are uncommon ; but coma, at least, ap- 
pears later, and may be preceded by rigors. In these cases, however, 
the cause is most frequently injury or septicemia ; whereas in the great 
majority of cases, which are the result of ear disease, the abscess 
during its formative stage gives rise to no symptoms except headache 
and disordered or weakened intellect, and may remain latent for months 
or even years. It may cease to be latent gradually, but more commonly 
latency ends abruptly, and symptoms of cerebritis and meningitis, occa- 
sionally with focal symptoms due to tumor, occur. The most important 
symptoms are fever, vomiting, headache, convulsions, paralysis, optic 
neuritis, and coma. The headache is persistent, and is often worse at 
the seat of disease. Vomiting is associated with constipation, fever, and 
sometimes with rigors and sweats. Convulsions are usually general, 
and are accompanied with paralysis, most frequently a hemiplegia. 
Rigidity of the neck and retraction of the head are not usually present, 
except when there is an associated basilar meniugitis. Optic neuritis, 
according to Gowers, is less common than in tumor, but more common 
than statistics would indicate. Delirium and coma usually close the 
scene. 

When the abscess runs an acute course, and there has been injury or 
an existing otitis media, it is to be distinguished from meningitis. This 
cannot be done unless there are focal symptoms and optic neuritis ; but 
abscess may be suspected if rigors are associated with the other symptoms. 

If cerebral symptoms develop suddenly after a period of latency, 
either from rupture of the abscess or rapid extension of softening, the 
phenomena are those of apoplexy. Abscess then can only be suspected 
when the previous history indicates a cause. 

When pressure symptoms exist, abscess is to be distinguished from 
tumor by the history ; by its relatively rapid development ; by the oc- 
currence of rigors and fever. Pronounced localizing symptoms are in 
favor of tumor. 

Tumors of the Brain and Its Membranes. 

Tumors of the brain and its membranes are twice as common in 
males as in females. The tubercular and syphilitic are the most com- 
mon, and next in frequency gliomata and sarcomata. Gowers states 
that the tubercular and sarcomatous tumors (including glioma and 
myxoma) constitute about four-fifths of non-syphilitic brain tumors. 
The same author says that three-fourths of the tubercular tumors occur 
during the first twenty years of life, and one-half the whole in persons 
under ten years of age. They occupy preferably the cerebellum and 
cerebrum. 

Headache, optic neuritis, vomiting, mental changes, and giddiness are 



DISEASES OF THE NERVOUS SYSTEM. 



843 



the most constant symptoms. The headache is constant, but subject to 
paroxysmal exacerbations ; occasionally the headache is unbearable ; it 
unfits the patient for all mental work, prevents sleep, and may induce 
great despondency. Optic neuritis is nearly always present, regardless 
of the seat of the tumor. Vomiting is more common when the tumor 
is at the base of the cerebrum or in the cerebellum. The most common 
form of mental change is a gradual decadence of mental powers, but 
there may be more or less marked mental aberration, and disorders of 
speech, consisting of a slow syllabic utterance perhaps oftener than of 
difficult articulation. The paralysis which occurs is usually a hemi- 
plegia or a monoplegia, which develops gradually and is associated with 
contracture. Occasionally the palsy is bilateral. 

Convulsions are common, and may be general, or commence in such 
a way as to indicate the seat of irritation, as in the foot or hand. 

The course of brain tumors is generally slowly progressive to a fatal 
issue in from six months to two years. Syphilitic tumors offer the best 
prognosis, and it is possible for tubercular tumors to become quiescent 
and encapsulated. (See Cerebral Localization.) 

Multiple Sclerosis. 

Multiple, disseminated, or insular sclerosis is a chronic degenerative 
affection of the brain and spinal cord which occurs preferably before 
middle age and in persons of nervous heredity. Its most constant 
symptoms are loss of muscular power in the limbs, a choreoid, jerky 
incoordination, especially marked in the arms ; nystagmus, vertigo, and 
scanning articulation. Disturbance of sensation is not characteristic of 
the affection, but it may be met with as irregularly distributed anaes- 
thesia or as paresthesia. 

There may be contraction of the field of vision before optic atrophy 
is discoverable • the latter is often developed in one eye before the other. 
Other symptoms occasionally present are vomiting, palpitation, and 
apoplectiform seizures. The general health of the patient remains 
good, and in spirits he shows surprising contentment. 

Toward the close of the disease there are bulbar symptoms, such as 
interference with respiration and deglutition. 

The duration of the disease is variable and its progress is not steadily 
retrograde ; there are periods when the disease appears to be stationary. 
As a rule, it lasts from two to six years, but may continue twice as 
long. The prognosis is fatal ; but the probability of length of life is 
to be judged from the rapidity with which the disease progresses and 
the presence or absence of bulbar symptoms and of complications — such 
as disease of the kidneys or bedsores. 

It is distinguished from locomotor ataxia by the fact that the in- 
coordination is most marked in the arms and that the reflexes are 
exaggerated, not diminished or absent. 

From general paralysis of the insane it is distinguished by the absence 
of mental changes ; by the articulation being slow, but accentuated and 
scanning, whereas that of paretic dementia is hesitating and indistinct, 
owing to difficulty in pronouncing certain consonants aud to spasm of 



844 



SPECIAL DIAGNOSIS. 



the tongue and lips ; by the absence of tremulousness about the mouth 
as seen in paretic dementia, and of the hallucinations and morbid im- 
pulses of the latter. Pupillary symptoms are less common in sclerosis 
than in general paralysis of the insane. 

From paralysis agitans it is distinguished by the irregularity of the 
incoordinated movements and by the fact that they cease when the 
patient is at rest ; whereas in paralysis agitans the movements are con- 
stant, rhythmic tremors. Moreover, in the latter the characteristic 
defects in articulation are wanting, and so are mental changes. 

Glosso-labial-laryngeal Paralysis. 

Glosso-labial-laryngeal, chronic bulbar, or progressive bulbar, paral- 
ysis is a chronic degeneration of nerve nuclei in the medulla, occurring 
most frequently after middle life, and characterized by slowly progress- 
ive loss of the power of articulation and of deglutition, with atrophy of 
the muscles concerned. The earliest symptoms manifest themselves in 
the tongue; there is difficulty in pronouncing words containing the 
lingual consonants, particularly I and t. At first the difficulty is 
noticed only when the patient is fatigued, and it can be overcome by 
effort; but eventually it is uncontrollable. The patient also loses 
gradually the power to protrude the tongue. In a short time the lips 
begin to lose muscular power; the patient can no longer pucker them, 
as in whistling, and has difficulty in pronouncing words containing the 
labial consonants, particularly p and b. Eventually he is unable to 
close the lips, and saliva constantly dribbles from them. Before the 
condition of the tongue and lips reaches its fullest development the soft 
palate becomes affected, and subsequently the pharyngeal muscles. 
Paralysis of the latter, with that of the tongue and soft palate, renders 
deglutition very difficult ; fluids tend to regurgitate into the nose, and 
solid substances and fluids find their way into the larynx. The con- 
dition of the patient is pitiable ; the intellect is undisturbed, so that he 
is fully conscious of his condition ; in fully developed cases the only 
sound he can make is from the larynx. The meaning of the sounds has, 
therefore, to be guessed with the aid of his gestures. Sensation of the 
affected parts is not impaired, though reflex action is lost. The patient 
is sometimes easily moved to tears or to laughter, and during such emo- 
tions the paralysis of the lower part of the face becomes very conspicuous. 

Progressive bulbar paralysis is often found in association with pro- 
gressive muscular atrophy, with or without spastic paraplegia. 

The course of the disease is progressive to a fatal issue in from one 
to five years. There may, however, be periods of temporary arrest of 
the disease. Death occurs from exhaustion depending upon insufficient 
nourishment, from bronchitis or pneumonia excited by particles of food 
being inspired, or from failure of respiration or heart. 

Chronic Hydrocephalus. 

Hydrocephalus implies an excess of fluids within the skull, either 
beneath the dura or within the ventricles. The former is called external 
and the latter internal hydrocephalus. 



DISEASES OF THE NERVOUS SYSTEM. 845 

Internal hydrocephalus may be congenital ; may occur after birth as 
the result of occlusion, usually from inflammation, of the openings into 
the fourth ventricle, or it may occur without ascertainable cause. It 
is characterized by a progressive enlargement of the skull; mental 
weakness frequently verging upon idiocy, and associated with physical 
weakness, occasional febrile attacks, convulsions, and vomiting. The 
eyeballs are prominent ; there is nystagmus and optic atrophy. 

In the congenital form the disease is present at birth and the 
enlarged head may form a serious impediment to labor. The head 
continues to grow in size, and may reach huge proportions. The 
fontanelles remain open, the skull is very thin, and the frontal portion 
projects over the face. The disease may progress rapidly and end in 
death from convulsions or wasting in a few months or a year, or at 
some stage it may be arrested and the patient live to an old age — with, 
however, feeble intellect and physique, and liability to epileptic seizures. 

In the acquired form the disease may develop at any age. Enlarge- 
ment of the head is less constant, but is not rare, after childhood ; in 
its absence a positive diagnosis is usually impossible. The general 
symptoms are the same as in the congenital variety. Life is not 
usually prolonged beyond a few years, and death may occur in as many 
months. 

Functional Nervous Affections. Chorea. 

Chorea occurs almost exclusively between the fifth and twentieth 
years of life, and is especially apt to occur about the age of puberty. 
It is nearly three times as common in girls as in boys, and its causation 
is influenced by a nervous heredity, by rheumatism, by the season of 
the year (spring), and by pregnancy. The most common immediate 
cause is fright. 

It is characterized by muscular twitching and jerky movements, 
irregular in time and rhythm, and occurring spontaneously. They 
tend to increase in frequency and range. They are at first controllable 
by a strong effort of the will, but only for a short time. Voluntary 
movements of the affected muscles become spasmodic, jerky, and in- 
coordinate. Muscular power is generally impaired, but not often to a 
very marked degree, and is very rarely lost. Electrical excitability is 
often increased. Sensation is unimpaired. The most common mental 
change is apathy, which may be so profound as to border on dementia. 

The disease begins gradually, the spontaneous jerky movements ap- 
pearing first most frequently in the hands or face ; in children regarded 
as emotional and excitable the movements are apt to be overlooked until 
they become more pronounced. The hands are moved involuntarily, 
or, when a voluntary movement is attempted, this is exaggerated in 
force or rapidity. If the patient attempt to pick up an object, he may 
succeed at the first attempt by a rapid jerky movement, or his hand 
may be carried beyond the object aud several efforts be necessary before 
the object is seized. Sometimes also the patient is unable to relax his 
grasp quickly. The mouth is drawn to one side or the eyes closed by 
spasmodic winking. The head also may be jerked forward, but the 
body and legs are not affected so often or to the same degree. By 



846 



SPECIAL DIAGNOSIS. 



degrees the movements increase in frequency and range, and in severe 
cases become so nearly continuous that rest and sleep are obtained with 
difficulty, and may be so violent as to result in severe injury to the 
patient. 

The disease may be limited to one side (hernichorea), but more fre- 
quently one side is more affected than the other, and it is most intense 
in the arms. 

In some cases there is moderate pyrexia. Heart murmurs may be 
hsemic, from ansemia; valvular, from mitral disease, or, very rarely, 
from aortic disease. Endocarditis is very common as a complication. 
The respiration is often irregular and the pulse accelerated. 

The duration of the disease is usually under six months, but relapses 
are common. Recovery is the rule ; but it is a grave complication of 
pregnancy, about one-fourth of the cases proving fatal. 

For the detection of the rare cases of paralytic chorea in which loss 
of power is more conspicuous than spontaneous spasmodic movements, 
Gowers suggests that the hand be held above the head, an action which 
brings choreic movements distinctly into play. The same author 
declares that " as a rule, when a child between seven and twelve years 
of age is said to have gradually lost the use of one arm, the disease is 
chorea." 

Paralysis Agitans. 

Paralysis agitans occurs most frequently between the fiftieth and 
sixtieth years. A nervous heredity has some determining influence. 
It is excited in some instances by shock, by fright, or by great mental 
anxiety ; injury, and the exhaustion of an acute disease may also act 
as exciting causes. It is characterized in its fully developed form by 
general muscular tremors, which are spontaneous and rhythmical, and 
are associated with muscular weakness and rigidity. It begins most 
frequently by tremor of one hand, the tremor extending to the arm, 
thence to the leg of the same side, then to the opposite arm, and being 
followed by muscular weakness and rigidity. A leg, however, may be 
attacked first, and weakness may precede the appearance of tremor. 
The tremor itself is a to-and-fro movement produced by alternate con- 
traction and relaxation of opposing muscles, and it continues during 
rest. The rigidity of the muscles causes flexion of the fingers and 
hands and, to a less extent, of the knees. The head falls forward, and 
the patient's gait is that known as " festinating," short quick steps 
being taken in rapid succession in order to preserve the equilibrium. 

The muscles do not waste until late in the disease, and even then the 
atrophy is rarely marked. The reflexes are usually normal. Dull 
pains in the limbs are common early in the disease, and later the con- 
stant movements cause weariness. A subjective sensation of increased 
heat in the affected parts is very common ; it may alternate with sensa- 
tion of cold, or the latter may be the more constaut. Pain is absent 
and the mind is unaffected, except that it shares in the general weak- 
ness. 

The disease progresses very slowly and may last many years, death 
generally being the result of intercurrent affections. 



r 



DISEASES OF THE NERVOUS SYSTEM. 



817 



Tetanus. 

Tetanus is an acute disease of the nervous system, the essentia] char- 
acteristic of which is persistent tonic spasm of the muscles of the jaws 
{lock-jaw) and of the spinal and trunk muscles. The disease begins 
with stiffness of the jaw, which steadily increases until, within a few 
hours, there is complete tonic spasm of the jaw. The neck muscles, 
and then those of the spine and trunk, become rigid, so that the body 
is arched backward and may rest upon the heels and head (opisthotonos). 
The facia] muscles share in the spasm, and by their contraction produce 
a horrid, grinning countenance (risus sardonicus). The contracted 
muscles become painful, and there is also epigastric pain. The rigidity 
is persistent, but is interrupted by exacerbations in which the phenomena 
already described are exaggerated, and in addition respiration is embar- 
rassed, the face becomes livid, the skin bathed in sweat, and the patient 
is further distressed with increased pain in the affected muscles. The 
body may be bent forward (emprosthotonos) or laterally (pieurosthotonos). 
The temperature is not constant. It may remain normal, be mod- 
erately elevated, or hyperpyrexia may be present, especially toward and 
after the close in fatal cases. The spasm ceases during sleep, but sub- 
sequently returns. 

The disease is most frequently traumatic in origin, but it may be 
idiopathic. Trismus neonatorum and puerperal tetauus are names 
given to special varieties which occur in newborn children and in puer- 
peral women. Tetanus is much more common in men than in women, 
and Gowers states that three-fourths of the cases occur between the ages 
of ten and forty. It is much more common in hot than in cold coun- 
tries, though cold is an exciting cause. 

In traumatic and puerperal cases the disease usually develops in from 
a few days to two weeks from the time of injury or childbirth or 
abortion. In newborn children it occurs usually during the first week. 
It lasts from two to six weeks, but may be fatal much earlier, or in rare 
cases last longer. The mortality ranges from 50 to 90 per cent. ; death 
is usually the result of heart failure or asphyxia, and occurs during an 
exacerbation of the tonic spasm. 

Tetany. 

Tetany is an acute affection of the nervous system characterized 
by spasmodic contractures, generally especially marked in the hands. 
These tonic spasms may be intermittent or continuous, and may be 
preceded or associated with paresthesia. The disease is afebrile, may 
occur at any age, but is most common before the twenty-fifth year, and 
its occurrence is aided by diarrhoea, cold, lactation and pregnancy, the 
acute infectious fevers, and excision of the thyroid ; in rare instances it 
occurs in epidemics. Tingling, burning, itching, or pain often precedes 
the appearance of the spasm, which generally seizes upon one or both 
hands first and then upon the feet. The fingers are flexed at the meta- 
carpo-phalangeal joints and the thumbs adducted ; the other joints are 
fixed in extension. The arms are flexed, but not strongly, at the elbow, 



848 



SPECIAL DIAGNOSIS. 



aud may be adducted. The feet are extended at the ankle, and inverted, 
while the toes are flexed. In mild cases the spasms are not more exten- 
sive, but in severe cases the muscles of the trunk, thorax, head, and 
face may be involved, with characteristic interference with function and 
distortion of features. The spasms may be intermittent, remittent, or 
continuous, and in severe cases are attended by cramp-like pain. Usually 
the spasms are intermittent, recurring at intervals of a few minutes or 
hours. As in tetanus, when very severe and extensive, respiration and 
heart action may be embarrassed, the temperature rise, and profuse 
sweating occur ; but the paroxysms become by degrees less severe ; 
though, unlike tetanus, they may appear first, or may persist during 
sleep. The nerves and muscles in the intervals are abnormally excita- 
ble, so that percussion or compression of them or of the corresponding 
arteries, or the application of electricity, readily excites spasm. Gowers 
states that it is the only affection in which anodal-opening tetanus has 
been observed in man. 

The duration of the disease is from a few days to a few weeks, 
depending upou its severity and upon whether the spasms are continuous 
or intermittent ; it may be prolonged beyond this time, especially when 
the cause is excision of the thyroid. Patients are liable to recurring 
attacks upon exposure to the exciting cause. The prognosis is favor- 
able to recovery in the large majority of cases ; but death may result 
from the combined exhaustion of the spasms and the causal disease 
(diarrhoea), and is most unfavorable in the form following excision of 
the thyroid. 

Writer's Cramp. 

Writer's cramp is the most important of a series of neuroses occur- 
ring in persons whose occupation necessitates prolouged use of a special 
group of muscles. According to the occupation of the sufferer it is 
common to speak of " telegrapher's," " pianoforte-player's," or " stone- 
mason's cramp." The pathology in each case is probably the same, 
and as the diagnosis is based upon the evidences of disability associated 
with the occupation of the patient, it will be sufficient to describe the 
symptoms present in writer's cramp with the understanding that they 
cover essentially what exists in the other varieties of occupation neuroses. 

Writer's cramp occurs most frequently in males from adolescence to 
middle life, and a nervous heredity has some causal influence. Injury 
to the hand or arm sometimes brings on an attack, but the most im- 
portant causal factors are excessive writing performed in a constrained 
position — the hand being fixed and the fingers making most of the 
motions. The same or a greater amount of writing performed by a 
shoulder motion rarely induces the cramp. Moreover, depression of the 
general health, especially by worry and anxiety, is liable to precipitate 
an attack. The characteristic symptom is a tonic spasm of the thumb 
and forefinger of the writing hand, less frequently of the other fingers, 
but sometimes involving, in severe cases, the hand and forearm, the 
spasm being brought on sooner or later after each attempt at writing, 
but not at first by other movements. The affection almost always 
comes on gradually ; the act of writing becomes slow and labored, the 



DISEASES OF THE NERVOUS SYSTEM. 



849 



fingers no longer contract and relax readily, but are stiff, and occasion- 
ally impart to the pen an unexpected motion, as the result of which 
the writing becomes angular, uneven, and too heavy. The fingers and 
hand also ache from weariness. The spasm tends to increase in intensity 
and range, and the writing becomes correspondingly irregular, difficult, 
and painful, until in severe cases, when various makeshifts have failed, 
all writing is found to be impossible. In such cases other movements of 
the same muscles are usually defective, display some incoordination, and 
may be followed by spasm. Tremor is rare. The muscular power is 
also apt to be impaired, but not to a great degree. 

In other cases the patient can draw, sketch, or play the piano, but 
cannot write. 

Pain is generally present, and sometimes is a prominent symptom ; 
usually it is dull and aching in character, but it may be neuralgic and 
show a greater disposition to extend than the motor symptoms. The 
disease is curable if taken in time and if the patient can cease writing, 
but the duration will depend upon the severity of the affection and the 
general strength of the nervous system. The affection is liable to recur 
unless the bad habit of writing is overcome. 

The diagnosis from degenerative affections of the brain or spinal 
cord, such as general paralysis of the insane and disseminated sclerosis, 
in which cerebral disease is sometimes first manifested by weakness and 
incoordination in the delicate movements of the hand, is to be made by 
noting the fact that, in the degenerations, other acts beside that of writ- 
ing induce it from the very beginning, and that there are general as 
well as local symptoms. 

From neuritis it is distinguished by the cause, the mode of onset, 
the presence of spasm, and the absence of the shooting pains and tender- 
ness along nerve trunks characteristic of neuritis. 

Epilepsy. 

Epilepsy is a chronic disease of the brain characterized by sudden 
convulsive seizures which are first tonic, then clonic, are brief in dura- 
tion, accompanied generally by complete loss of consciousness and often 
by cyanosis, and occur apart from organic brain disease, toxaemia, or 
other obvious cause. The attacks are not followed by any motor or 
sensory palsy, nor usually by any mental disturbance beyond drowsi- 
ness. 

The disease may occur at any age, but the great majority of the cases 
occur before the twentieth year. Epilepsy or insanity in the parents 
predisposes to it. Exciting causes are convulsions during teething, 
especially in rickety children, worry, fright and anxiety, acute disease, 
particularly scarlet fever, and injuries to the head. 

The attacks may be severe {grand mat) or mild (petit mat). The 
severe attacks are marked by loss of consciousness and falling to the 
ground, if the patient be standing. The muscles are first fixed in tonic 
rigidity, the eyes open, the face pale, and respiration embarrassed, with 
conjugate deviation of head and eyes. Soon the cyanosis lessens, the 
convulsive movements become clonic instead of tonic, respiration comes 

54 



850 



SPECIAL DIAGNOSIS. 



in noisy puffs, and by degrees the patient falls into a heavy sleep or 
wakens to complete consciousness, but generally suffers with a headache 
for a while afterward. It is very common for patients to have warning 
(aura) of the approach of an attack. This may consist of flashes of 
light before the eyes, or of a sensation or motion in the arm, face, or 
leg. Sometimes also the convulsion begins in one arm or in the face. 
During the convulsion, biting of the tongue and involuntary discharge 
of urine are common and very characteristic symptoms. The convul- 
sions recur at very irregular intervals ; and many occur in one day, or 
they may be delayed for weeks and months. Moreover, they may be 
diurnal or nocturnal, and when exclusively nocturnal they may escape 
the detection of the patient and his friends for years. 

When they are suspected, inquiry should be made as to the existence 
of a bitten tongue, of subconjunctival hemorrhage, or of nocturnal 
enuresis. 

Rarely there is a series of convulsions uninterrupted by intervals of 
consciousness (status epilepticus). 

After attacks patients are conscious, but usually dull and drowsy ; 
sometimes they are very quarrelsome, and may commit acts of violence. 

In the milder cases, classed as petit mal, the seizures vary widely in 
symptoms, but they consist in general of a disturbance of sensation, less 
frequently of motion, associated with a partial loss of consciousness. 
The patient becomes momentarily giddy and faint, sits down or grasps 
an object for support, a mist comes before his eyes, and he loses con- 
sciousness partly or completely, but only transiently. Slight convulsive 
movements may occur, but are not nsual. 

Urine may be voided unconsciously. The patient remains dazed for 
some moments after the attack and may commit strange actions ; that of 
undressing is said to be one of the most frequent. 

The duration of the disease is very uncertain. When it has existed 
for several years it is rarely cured. The best prospects of cure are in 
those over twenty years of age, when the fits occur at long intervals 
and when treatment can be kept up continuously. Death does not 
often occur during a convulsion, but fits occurring in dangerous places 
not uncommonly lead to accidental death. Life is shortened by it, but 
it is difficult to say to w T hat extent. 

Hysteria. 

The manifestations of hysteria are seen in permanent symptoms, 
known as the stigmata, and in the hysterical attacks. 

The stigmata are often detected only by special examination. The 
patient is not usually cognizant of their presence. 

1. Sensory Anaesthesia. The sensibility of the surface and the 
special senses are affected. Analgesia is common. It may be general 
or limited to an arm or a leg, or to areas on the limbs or trunk. Other 
forms of cutaneous sensibility may not be affected at the same time, al- 
though any variety of anaesthesia may occur. The muscular sense may 
be lost. Eye symptoms, due to disturbance of the sensibility of that 
organ, are common. Vision may be distinct or dim. Limitation of the 



DISEASES OF THE NERVOUS SYSTEM. 



851 



visual field is common, and most characteristic. Achromatopsia, alter- 
ation of color sense, is common in hysteria. Diminution of hearing and 
loss of smell and taste are common sensory symptoms in this affection. 

Hemianesthesia is a common symptom of hysteria. One-half of the 
body seems to have lost consciousness. The skin bleeds in small 
amounts when wounded. The mucous membranes are affected, as the 
conjunctiva, half of the buccal cavity, and the tongue. The muscular 
sense is lost. There is diminution of the sense of hearing on the affected 
side, and loss of the sense of taste and smell in the corresponding posi- 
tions. Amblyopia, or amaurosis, occurs in the eye of the corresponding 
side. 

In hysteria, hypersesthetic regions are of common occurrence. These 
areas or " hysterogenous zones " are important manifestations. The 
sensitive points are tender on pressure, although when the patient's 
thoughts are diverted firm pressure is not observed. The hyper aes- 
thetic areas are often the seat of pain. 

These areas may be extensive or quite circumscribed. They are 
most common in the head and trunk, on the sides of the chest, under 
the breast, and on the sternum. Hyperesthesia of the spinal column 
and of the lower abdominal region is of very common occurrence. The 
whole spine or small portions only of it are affected. A slight pressure 
may cause severe pain. Hyperesthesia of the eye, ear, and other 
senses occur. 

2. Hysterical Paralysis. A frequent manifestation of hysteria is 
paralysis of one or more groups of muscles. It may occur suddenly or 
come on gradually. The paralysis is of central origin, due to loss of 
the power of will to effect contraction of the muscles. The following 
muscles in order of frequency are affected : 1. The muscles of the 
lower limbs. 2. The vocal cords. 3. The pharynx and oesophagus. 
4. The muscles of the arms. Hysterical paralysis of the facial muscles 
does not occur. In paralysis of the lower linbs the patient may be able 
to move the legs in bed, but cannot walk. Both flaccid and spastic 

'paralyses are seen in hysteria. The tendon reflexes may be exag- 
gerated. 

3. Hysterical Contractures. Contractures occur alone or with anaes- 
thesia or paralysis. They may be temporary, but often become perma- 
nent. In the hands and feet there are flexor contractures. Extensor 
contractures are more common when the muscles of the large joints are 
affected. They often follow a convulsion and may be limited to one 
entremity, to the extremities of one side of the body, or the lower ex- 
tremities alone. 

4. Vasomotor Disturbances. The surface of the skin may be cool 
and pale, or hot and red. The two conditions may alternate. The 
affected portion is limited to an extremity, or to the skin about a joint. 
Among other vasomotor disturbances frequently seen, hemorrhages 
from internal organs take place. Hsernatemesis, haemoptysis, and other 
bleedings may be found. 

Hysterical 'fever has been observed. The increased temperature 
occurs at the time of an attack of hysteria. Care must be taken that the 
rise of the mercury is not produced by rubbing and pressing the ther- 



852 



SPECIAL DIAGNOSIS. 



mometer by the patient. The temperature should be taken in the rec- 
tum. Modifications in the secretory organs are common. The per- 
spiration may be increased or absent. The flow of saliva is similarly 
modified. Ischuria or diminished secretion of urine is often seen. 
Polyuria of hysterical origin is more common. The urine is light in 
color and of low specific gravity. 

5. Visceral Symptoms. The most common perversions of the func- 
tions of internal organs are seen in those belonging to the gastrointesti- 
nal tract. They have been fully dealt with in the section on diseases 
of these organs. In addition to the manifestations mentioned, hysteri- 
cal tympanites is of common occurrence. The accumulation of gas 
simulates tumor, pregnancy, or peritonitis. Under anaesthesia the 
hysterical tumor is dissipated. The gas may be removed by a rectal 
tube. 

In other portions of this work reference has been made to the cough 
of hysteria, and to a peculiar form of pulmonary hemorrhage seen in 
hysteria. Increased frequency of respiration, modification of the nor- 
mal rhythm, and dyspnoea, usually unattended by distress and with 
normal pulse, are frequent phenomena of pulmonary hysteria. 

In cardiac hysteria increased frequency of the heart's action on the 
slightest emotion, with or without precordial distress, is common. 

Hysterical or pseudo-angina often occurs. Flushes, both general and 
local, are common symptoms. The joints are frequently affected in hys- 
teria (see p. 143). 

The Mental Constitution. The characteristic of the patient most 
paramount is selfishness. The various forms of expression of feeling 
are almost always excited by the desire of the patient to attain some 
object. The patients are irritable and emotional. They are easily de- 
pressed, extremely sensitive, and subject to violent emotional expressions. 
They exaggerate their sufferings, do everything to command attention, 
and attempt to excite sympathy. Any desire that is to be accom- 
plished is secured by sly means, to say the least, or actual deception. 
The will-power is lost entirely or enfeebled. The patients are usually 
bright and vivacious, or emotional in turn. Mental characteristics 
may be absent entirely. 

The general nutrition may not be affected, although the ill nourished 
and weakly are more often hysterical. 

Hysterical Attacks. A so-called attack of hysteria may be the first 
manifestation of the disease, or the patient may not become subject to 
such attacks until some time after the permanent stigmata have 
developed. The attacks may be made up of subjective symptoms 
only, the patient complaining of vertigo, anxiety, precordial or respira- 
tory distress, a sense of fulness in the throat, or a lump in the 
oesophagus (globus hystericus). The objective symptoms of hysteria 
are seen in aberrant displays of emotion or convulsive movements, with 
or without a loss of consciousness. Convulsions may be preceded by 
emotional disturbance, or by painful sensations in the chest or abdomen. 
In the minor convulsions the movements' are clonic and irregular. 
Each series of convulsive movements lasting a few minutes, is followed 
by an emotional attack, when consciousness, which was lost, is restored. 



DISEASES OF THE NERVOUS SYSTEM. 853 



Instead of convulsive movements the patient may fall into a relaxed 
state with unconsciousness. At the time of the attack the abdomen 
may be distended with flatus. Urine light in color is passed in large 
amounts afterward. 

Hystero-epilepsy is the most exaggerated convulsive form. The attack 
may come ou suddenly, or be preceded by milder hysterical symptoms. 
Areas of hyperesthesia are ofteu detected at this time. They are more 
marked over the ovaries and the upper dorsal vertebra. The attack is 
preceded by the globus or by a feeling of extreme oppression. The 
attack is divided into four stages. In the first stage an epileptic 
paroxsym is simulated. The convulsions, which are at first tonic, are 
followed by gradual relaxation and coma. The duration of the attack 
is longer than epilepsy. Following the convulsions there is a violent 
display of emotion with contortions ; and cataleptic positions are as- 
sumed. In the third stage peculiar attitudes are assumed which express 
the various passions. This period is followed by a return of conscious- 
ness, with delirium and hallucinations. This, the fourth stage, may con- 
tinue for several days. The attacks may recur for days, followed by a 
trance-like state which in turn may continue for a long period. 

The diagnosis of hysteria is based upon the presence of the stigmata, 
the peculiar character of the pain, the occurrence of emotional attacks, 
and the globus hystericus. The pain and other subjective symptoms are 
influenced by suggestion. The paralyses are usually associated with 
anesthesia. They are always variable. All forms of organic paralyses 
may be simulated by hysteria. 

Neurasthenia. 

The symptoms may be general or local or may be combined. The 
patient is usually under weight, and more or less anemic. Debility 
may be so marked as to compel the patient to remain in bed. Local 
neurasthenia is expressed in cerebral, spinal, cardio-vascular, gastric, 
and sexual forms. In cerebral neurasthenia there is sensation of 
weight and fulness in the head, with flushes. The patient may be 
drowsy, and is usually irritable and depressed. Headache may be 
complained of. The pain is most common in the back of the head or 
the neck. Neck weariness is a common symptom. Any mental effort, 
even of the smallest degree, is accomplished with difficulty. The 
smallest amount of mental work may require a painful effort. The 
patient is likely to complain of aching and weariness of the eyeballs 
after reading a few minutes. Flashes of light are often present. 

The symptoms of spinal neurasthenia are those of what was formerly 
termed spinal irritation. Local tenderness is found all along the spine 
in small areas. In the cervical spine aching is common. The patients 
weary on the slightest exertion, and are subject to backache and aching 
pains in the legs. 

Cardio-vascular symptoms, as palpitation of the heart, irregularity, 
increased frequency, and precordial pain are common. Vasomotor 
symptoms are most pronounced. Flushes of heat and transient 
hyperemias are frequently seen. Sweatings may occur. Arterial 



854 



SPECIAL DIAGNOSIS. 



throbbing is very common. The capillary pulse can often be seen. 
Throbbing of the aorta and of the carotids are most common in 
neurasthenia. 

The gastro-intestinal symptoms have been discussed in Chapter V. 
Neurasthenia is frequently associated with lithsemia. 

Pain in the Head. 

Pains in the head may be classified according to location into those 
due to affections of the scalp, those due to affections of the cranium, 
and those due to intra-cranial conditions. 

I. Affections of the scalp are to be further classified as those of the 
skin, those of the occipito-froutalis muscle, and those of the nerves. 
The occurrence of itching and burning commonly indicates some local 
condition of the skin ; if the itching is slight seborrhoea should be 
looked for ; if more severe, eczema ; and burning and itching of a 
severe type commonly indicates dermatitis venenata; the pedieulus 
capitis should not be forgotten. A feeling of tension with soreness 
accompanies the eruption of erysipelas. Intense local irritations are 
caused by burns and scalds, the latter, however, because the hair is 
not immediately destroyed, is alone likely to give rise to error. A sore 
feeling with local tenderness, limited to a swelling sharply delimited, 
with a sensation of less resistance in the centre and some darkening of 
the skin is diagnostic of a bruise. Hypersesthesias of the scalp fre- 
quently accompany meningeal and cranial affections, and there are even 
local changes, such as the so-called puffy tumor of necrosis of the inner 
table of the skull. 

Sharp pains in the occipital or frontal region, increased by wrinkling 
the scalp, or brief pressure, but generally relieved by firm and con- 
stant pressure, occurring with irregular periodicity, and associated 
with meteorological changes, are suggestive of occipital myalgia. 
The diagnosis is confirmed by the presence of other symptoms of 
litbsemia. 

The sensory nerves of the scalp and face are the trigeminus and the 
branches of the cervical plexus. The distribution is as follows : the 
ophthalmic division of the trigeminus is distributed to the eyeball, 
lachrymal gland, the mucous membrane of the nose and eyelids, the 
integument of the nose and upper eyelid, the forehead and the anterior 
half of the hairy scalp. The superior maxillary division supplies the 
skin over the malar bone, and that of the lower eyelid, side of the nose, 
and upper lip ; the upper teeth, the upper part of the pharynx, the 
antrum of Highmore, and the posterior ethmoidal cells ; the soft 
palate, tonsil, and uvula, and the glandular structures of the roof of the 
mouth. The inferior maxillary division is distributed to the side of 
the head, the upper anterior portion of the external ear, the external 
auditory canal, the lower lip, and lower part of the face ; the tongue, the 
mouth, the lower teeth and gums, the salivary glands, and the articula- 
tion of the jaw. The great occipital is distributed to the back of the 
head, the small occipital to a narrow region just in front of it, and the 



DISEASES OF THE NERVOUS SYSTEM. 



855 



great auricular to the skin of the posterior portion of the pinna and the 
skin over the mastoid and parotid gland. 

Neuralgia occurs in the form of paroxysms of pain accurately 
located in the course of one or more of the nerve trunks, and presenting 
points of special sensitiveness where the nerve emerges from the skull, 
and where it divides for its cutaneous distribution. The pain is usually 
relieved by firm pressure, but it is to be remembered that sharply local- 
ized pressure on the nerve trunks against the hard skull will cause a 
traumatic tenderness. The character of the pain is variable : it may be 
of the most acute or rending form, or, but more rarely, a persistent dull 
ache ; it may be throbbing, or in successive paroxysms at brief intervals 
or regularly periodic. There are often associated vasomotor, secretory, 
and motor disturbances ; and local blushing or sweating may be 
observed along the course of the nerve ; and spasms may occur in the 
muscles, as of the eyelid, or more general as in the terrible tic doulou- 
reux, distinguished by the pain from tic convulsif. The commonest 
seats are the supra-orbitals, the dentals, the auricular branches, and 
the occipitals ; in the great majority of cases it is unilateral. 

Pain, undistinguishable from neuralgia, is frequently due to some 
local irritation ; foreign bodies have been known to cause paroxysmal 
attacks for a number of years, until removed ; diseases of the bones are 
a prolific source, especially in the case of the jaws and the cervical 
vertebrae. Enlarged cervical glands occasionally irritate the great 
auricular or small occipital. Bilateral occipital pain is very characteristic 
of cancer of the cervical vertebrae. In these cases there is usually 
pain upon movements of the head or pressure upon it, and some 
stiffness of the neck. Intra-cranial growths occasionally cause 
pains, usually paroxysmal, limited to one of the branches of the tri- 
geminus. 

Certain of the cephalic nerve pains are symptomatic of disturbance 
of the associated but distant nervous distribution. Pain in the region 
supplied by the ophthalmic division is very common in influenza. It 
is usually dull, aching, and continuous, increased by pressure and any- 
thing tending to increase congestion. A severe acute attack of indiges- 
tion will produce ocular and supra-orbital pain. Refractive lesions of 
the eye cause the same character of pains, but increased by using the 
eye and relieved by rest and atropine. The use of the latter is an im- 
portant diagnostic procedure. Pain in the temporal region and the 
external auditory meatus is often due to intense irritation of some of 
the branches of the inferior dental ; the usual cause is cancer of the 
tongue, but irritable lingual ulcer may also produce it, and even severe 
inflammatory conditions of the lower jaw. The pain is described as 
sharp and lancinating and paroxysmal, liable to exacerbations, 
especially when the primary lesion is excited, and relieved when it is 
alleviated. Pain may be caused in the ear alone, when there is irrita- 
tion of the teeth. 

Perhaps in the majority of cases of cephalic neuralgias the cause is to 
be found in some systemic disturbance. If the attack is preceded by a 
desire to sleep, occurs when the dew-point is high, and is associated with 
increase of urates in the urine, it is probably lithwmic ; the pure gouty 



856 



SPECIAL DIAGNOSIS. 



forms are more apt to succeed indulgence in rich food or heavy meats 
and there is ordinarily irritability of temper. Diabetic neuralgias 
invariably are worse as the amount of sugar excreted is increased, and 
there are usually similar affections of the nerves in other parts of the 
body. Regularly periodic pains, worse in the spring and fall, occasionally 
preceded by a slight chill or malaise, suggest chronic malaria. The 
diagnosis can readily be confirmed by examination of the blood, and 
detection of enlargement of the spleen. Syphilitic neuralgias are 
usually worse at night ; the pain is described as boring, and may 
indeed simulate periodicity. There is apt to be some thickening of the 
bones, and perhaps a diminution of elasticity of the tissues, and almost 
always local tenderness. The pain is almost immediately improved by 
potassium iodide. In anwmic neuralgias the pain is not characteristic, 
but they are temporarily improved by the recumbent posture and 
stimulants, and is worse during menstruation. The general appear- 
ance of the patient and an examination of the blood readily suggest 
the cause. In locomotor ataxia there are occasional cephalic crises of 
neuralgic nature ; these come on suddenly and are exceedingly severe, 
but usually occur only at long intervals ; the pain is shooting or stab- 
bing and does not remain located to one nerve trunk. Chronic lead 
and alcohol poisoning also cause neuralgias, but they are not of them- 
selves characteristic and never occur as isolated symptoms, being fre- 
quently associated with peripheral neuritis of other parts. 

Dull burning pains commencing perhaps with a chill, and accom- 
panied by febrile symptoms, indicate inflammations of the mucous mem- 
branes of the head. A dull persistent headache located just beneath 
the eyebrows often accompanies coryza and indicates extension to the 
frontal sinuses; if the nose alone is involved there is a feeling of fulness 
and occasional sharp pains or tickling sensations. A feeling of dryness 
and some discomfort on swallowing accompanies the various forms of 
stomatitis and pharyngitis ; in the latter there is also a sensation of 
tickling and fulness in the ear, due to extension along the Eustachian 
tube. Pain at the angle of the jaw, with tenderness and increased on 
swallowing, almost invariably unilateral and associated with swelling of 
the parotid, is unmistakably parotitis. The neuralgias and inflamma- 
tions of the middle ear are exceedingly painful ; they may consist of a 
sharp continuous pain, or a series of regular exacerbations and remis- 
sions, or a throbbing sensation ; often pain radiates to the jaws and side 
of the face. As suppuration occurs the feeling becomes one of extreme 
tension until the membrane is perforated, when there is immediate 
relief. Tinnitus throughout the whole course of the case is very com- 
mon. The inflammations of the eye produce local pain, usually caus- 
ing the sensation of a rough foreign body. Usually there is slight 
supra-orbital tenderness, and in iritis sharp pains radiate over the whole 
area of distribution of the two upper branches of the fifth. Certain 
ulcers of the mouth are comparatively painless ; noma often developing 
insidiously; while syphilitic ulcers are to be distinguished by their pain- 
lessness from simple and tubercular ulcers, which are very irritable, 
and carciuomata, which are liable to paroxysms of pain even when not 
irritated. 



DISEASES OF THE NERVOUS SYSTEM. 



857 



It may not be out of place to mention the value of certain anaesthesias 
as diagnostic signs ; thus in neuritis of branches of the fifth, there may 
be cutaneous anaesthesia while there is tenderuess over the nerve trunks. 

II. A dull, constant headache, limited to a small area, later increasiug 
in severity, and the pains assuming, perhaps, a boriug character; ten- 
deruess, often very severe, over the affected area, and probably slight 
oedema of the scalp, with some rigidity of the muscles of the neck, and 
the ordinary signs of the inflammatory process, indicate inflammation of 
the cranial bones. In the simple cases there will usually be some 
history of injury, the pains will not be especially periodic, and the fever 
irregular. In the syphilitic cases there will be the history and symp- 
toms of infection, the pain will become especially worse at night, aud 
usually there will be concomitant rise of temperature. The pains will 
also be controlled by potassium iodide, but as it often requires enor- 
mous doses to accomplish this result, the failure of a moderate dose 
should not be consider ed as exclusive. 

III. Intra-cranial Headaches. Intra-cranial headaches are 
functional or organic. Both forms may be acute or chronic. The 
typical acute functional headache is seen in the more or less common 
type known as migraine or hemicrania. 

Migraine is a periodical neurosis characterized by pain affecting the 
trigeminus and other cranial nerves. The headache is usually unilat- 
eral, and while probably due to vasomotor disturbances is always asso- 
ciated with vasomotor symptoms. It occurs more particularly in 
women, frequently begins in early childhood and continues throughout 
adolescence. It is often hereditary. It occurs most frequently in 
women who suffer from anaemia or from menstrual difficulties. The 
habit which predisposes to the headache may develop after long physical 
or mental over-exertion. The attacks, however, are excited by over- 
exertion, mental excitement, or disturbances of digestion. Pain of 
migraine is possibly situated in the pia and dura mater. 

Symptoms. The attack develops with or without premonitions. In 
each individual different prodromal symptoms are recognized as indi- 
cating the approach of an attack. Undue nervousness, a general sense 
of discomfort, pressure or heat in the head, vertigo, tinnitus, spots 
before the eyes, excessive yawning, or repeated chilliness are the most 
common. 

Premonitory Symptoms. The pain is most frequently felt on the left 
side of the head first. It is seated in the anterior frontal, the temporal, 
or parietal regions. The pain is continuous and increases in intensity to 
the height of a paroxysm. Painful points are not usually detected, 
although the whole skin may be hyperaesthetic. The patient is sensi- 
tive to light and sound, intolerable nausea intervenes, and vomiting 
may occur at the height of the attack. The eye symptoms are very 
pronounced. Flashes before the eyes, scintillating scotoma, or hemi- 
anopia may occur. 

The vasomotor symptoms that attend the attack are of two varie- 
ties, causing the disease to be divided into the spastic and angio-par- 
alytic forms. In spastic migraine the skin on the affected side is cool, 
the forehead and ear pale, the temporal artery is contracted, the pupil 



858 



SPECIAL DIAGNOSIS. 



is dilated, and the flow of saliva increased. In the paralytic form there 
is redness of the face on the affected side. The temporal arteries are 
dilated and pulsate strongly. The face is hot, the pupils contracted, 
aud there is often unilateral sweating. 

Chronic Headaches. Chronic headaches of functional origin are 
usually habitual as to the constancy of attacks, although the period 
between the attacks may vary. The nerves affected are the trigeminus, 
the four upper cervical and sensory branches of the vagus to the poste- 
rior fossa of the skull. Three types of such head pains are seen : ordi- 
nary headache, migraine, and neuralgia. Headaches are caused as a 
rule by diffuse irritations located in or referred to the peripheral ends 
of the nerve tracts above referred to. Neuralgias, on the other hand, 
are caused by irritations of the trunks of these nerves. 

Causes. 1. Hsemic. a. Anaemia, b. Diathetic states (gout, rheu- 
matism, diabetes). c. Infections (malaria, syphilis, specific fevers). 
2. Toxic (lead, aud other mineral poisons, alcohol, uraemia, tobacco). 3. 
Neuropathic states (epilepsy, neurasthenia, chorea, hysteria, neuritis). 
4. Reflex causes (ocular, naso-pharyngeal, auditory, gastric, sexual, 
uterine). 5. Organic disease. 

Fig. 162. 

Anaemia. 

Endometritis. 

Bladder. 



Constipation ; caries of incisor. s 

Error of eye refraction. v 
Gastric dyspepsia. _. 




teeth. 

[itis; otitis media. 



Showing the location of pain in various headaches. (After Dana.) 

Headaches are divided according to their situation into frontal, oc- 
cipital, parietal, vertical, diffuse, and combinations of both. The most 
common forms are the frontal, the frontal-occipital, and the diffused. 
Ocular headaches are usually frontal, when due to errors in refraction. 
When due to muscular insufficiencies they are occipital and cervical. 
Naso-pharyngeal headaches are dull frontal or diffused. When the 
pharyngeal tonsil is enlarged the headache may be dull, frequently 
recurring and seated in the occipital region. In follicular tensillitis the 
headaches are diffused. In obstruction of the Eustachian tubes they 
are diffused. In disease of the middle ear they are temporal and oc- 
cipital. Gastric or dyspeptic headaches without constipation are often 
occipital, sometimes frontal. With constipation and intestinal irrita- 
tion they are diffused and frontal. Uterine and ovarian headaches are 
occipital and vertical. Neuropathic headaches are seated on the top of 
the head, as in clavus, or are associated with spinal irritation. Nenras- 



DISEASES OF THE NERVOUS SYSTEM. 



859 



thenic headaches are usually associated with a sense of pressure or 
weight, and are seated in the frontal and vertical regions. In spinal 
irritation the pain is of a boring character in the occipital region. The 
earliest symptom of the neurasthenic headache is neck weariness and 
pain in the neck. The neurasthenic headaches occur in brain -workers, 
when the brain and eyes are overtaxed. Headaches in epilepsy are 
severe, and are confined to the vertical or occipital region. Organic 
headaches are usually violent, associated with fulness and throbbing. 
They may be remittent, becoming more intense with each exacerbation. 
The organic headaches may be due to inflammation, to abscess and 
softening, to tumor, to congestion of the brain, and to inflammations 
in the meninges. Anything which increases the blood will increase 
the pain in organic headaches. In acute inflammation of the brain the 
pain is agonizing, continuous, associated with vomiting and fever, and 
sometimes delirium. In abscess of the brain the pain is less violent. 
It is occasionally paroxysmal and attended by paralyses and dis- 
turbed intellection. In tumor of the brain the headache is severe and 
paroxysmal. In congestion the pain is dull, increased by stooping, by 
sleep, and by bodily or mental fatigue. Some congestive headaches 
are due to violent exercise and relieved by bleeding at the nose. In all 
congestive headaches the face is flushed, the bloodvessels are turgid, 
and the vessels in the eye-ground will be found to be overloaded. In 
meningitis the pain is constant, is more or less fixed, and sometimes 
very sharp. Syphilitic headaches are frontal or temporal, worse at 
night, and often periodic. 

Headaches are divided according to the character of the pain : 1. 
Pulsating and throbbing. 2. Dull and heavy. 3. With constriction, 
squeezing, or pressing. 4. Hot and burning. 5. Sharp and boring. 
The headaches of the first class are usually associated with vasomotor 
disturbances, as in migraine ; to the second class belong the toxic and 
dyspeptic headaches ; to the third the neurotic and neurasthenic ; to 
the fourth rheumatic and anaemic ; to the fifth hysterical, neurotic and 
epileptic. Vertigo is a common accompaniment of the dyspeptic type 
of headache situated in the frontal regions. Somnolence is more 
marked in the syphilitic, anaemic, and malarial headaches. Nausea is 
more common in occipital forms of headache. 

Duration. Eye-strain causes occipital pain, which is rarely persistent, 
but comes on after prolonged use of the eyes. It may be associated with 
headaches in other parts, due to other causes. In chronic meningitis the 
headache is persistent and located in the vertex or the parietal regions. 
When thickening of the meninges with adhesions take place from 
trauma there is constant pain, sensitiveness of the head, incapacity for 
study, and frequent exacerbations of the pain. Ursernic headache is 
inconstant. Persistent headache may in the latter stages of Bright's 
disease be present. In diabetes persistent headache occurs. In ather- 
oma pain in a part or the whole of the head is common. It may be 
persistent though subject to exacerbations in case of excitement or 
violent exercise. Headache following study in children is due to brain 
strain, to the eyes, or to indigestion. Persistent headache is sometimes 
due to asthma. In rare instances headache is said to be idiopathic. 



860 



SPECIAL DIAGNOSIS. 



Neuralgic headaches are usually periodic and may be associated with 
throbbings or pulsations. They are associated with vasomotor signs. 
Hysterical headaches are irregular and shifting; they persist after 
all causes are removed ; they are replaced by pain in other parts of 
the body. They are usually associated with other manifestations of 
hysteria. 



INDEX. 



ABDOMEN, aspiration of, contra-indica- 
tions to, 160 
color of, 473 

diminution in size of, 473 
general enlargement of, causes of, 470 
palpation and percussion of, 474 
local enlargement or tumors of, 472 
markings on, 473 

method of marking surface of, 468 
movements of, 473 

palpation and percussion of lower 

quadrants of, 475 
peristaltic movement seen through 

walls of, 474 
point for puncture of, 160 
quadrants of, contents of, 468 
shape of, 473 
superficial veins of, 474 
tumors in, 478, 479, 480 
tumors of, epigastric pulsation in, 368 
walls of, in peritonitis, 475 

pain due to disease of structures 
of, 469 
Abscess, fecal, 477 
gouty, 714 
pelvic, 476 

pericecal, causes of, 572 

distinguished from appendicitis, 
571 

perigastric or subdiaphragmatic, 479 
perinephritic, 680 

distinguished from appendicitis, 
571 

precordial, 386 
retro-pharyngeal, 460 
stitch, cause of, 163 
subphrenic, 337 
Acid, hvdrochloric, in gastric contents, tests 
for, 490 
uric, 662 
Acetonemia, 668, 718 
Acetonuria, 648 
Acromegalia, 65 
Actinomyces, 164 

in sputum, 281 
Actinomycosis, 772 
Acute peritonitis, facies in, 118 
Addison's disease, 699 

bronzed skin in, 74 
pigmentation of buccal mucous 

membrane in, 431 
tongue in, 439 
Adenitis, diagnosis of, 134 



^Egophony, 263, 330 _ 

Age, in aetiology of disease, 24 

influence on temperature, 102 
Albuminometer, 641 
Albuminuria, causes of, 642 

functional, 642 

in tonsillitis, 455 
Alcoholism distinguished from apoplexy 
839 

Amaurosis, uremic, 667 
Amblyopia, tobacco, 807 
Amoeba dysenterie, 553 
in feces, 539 
in pus, 162, 166 
in sputum, 275 
Anemia, 688 

cardiac murmurs in, 366 

classification of, 689 

clinical divisions of, 172 

from hemorrhage, 690 

hemorrhage in, 78 

idiopathic or pernicious, 691 

in constitutional and local diseases, 690 

in interstitial nephritis, 675 

in nephritis, 670 

local, 173 

Mackenzie's rule for detecting, 132 

murmurs in, 381 

neuralgia in, 856 

oedema in, 93 

parasitic, 689 

splenic, 697 

toxic, 689 

venous hum in, 384 
Anesthesia, cerebral, 789 

in hysteria, 850 

of skin, 788 

spinal, 789 
Anasarca, 92 

cardiac, 95 

of Bright' s disease, 95 
Aneurism, aortic, 421 

bronchorrhoea in, 423 
conditions with which con- 
founded, 428 
confounded with phthisis, 423, 
428 

diagnosis of, 427 
general symptoms of, 422 
physical signs of, 425 
precordial pain in, 386 
symptoms of, 422, 423 
tracheal tugging in, 427 



862 



INDEX. 



Angina Ludovici, 449, 460" 

pectoris, arterial tension in, 373 

associated with arterial sclerosis, 
421 

cardiac lesions with which asso- 
ciated, 387 
diagnosis of, 387 
false, 388 

in aortic incompetency, 405 
pain due to, 387 
Angle of Ludwig, 228 
Anidrosis, 77 
Anilines, basic, 153 
Ankle clonus, 793 
Anorexia in gastric neuroses, 515 
Anthrax, 774 

bacillus of, 165, 775 
Antrum, abscess of, 199 

lacrymal duct in, 200 
obstruction of duct of, 200 
Aorta, aneurism of (see Aneurism). 

epigastric pulsation in, 369 
atheroma of, cardiac murmurs in, 
367 

diseases of, pain in, 386 

pulsation of, 368 

confounded with aneurism, 428 
Aortic incompetency, 404 
arteries in, 406 
general symptoms of, 405 
pharyngeal hemorrhage in, 451 
physical signs of, 405 
pulse in, 406 
thrill in, 406, 348 ^ 
valvular murmurs in, 406 

obstruction, 406 
thrill in, 348 
Apoplexy," 837 

conditions with which confounded, 
839 

distinguished from embolic softening, 
839 

in interstitial nephritis, 676 
ingravescent, 838 

pain in extremities, forerunner of, 45 

seats of hemorrhage in, 838 

vomiting as symptom of, 500 
Appendicitis, conditions with which con- 
founded, 571 

confounded with intestinal colic, 527 
with typhoid fever, 733 

distinguished from intestinal obstruc- 
tion, 566 

recurrent, 569 

with perforation, 570 

without perforation, 567 
Appendix, diseases of, palpation and per- 
cussion in, 475 
Apraxia, 798 
Aprosexia, 458 
Arcus senilis, 124 
Arteries, auscultation of, 380 

disease of, subjective symptoms in, 391 

of the neck, pulsation of, 368 

pulsation of 389 



I Arteries, sclerosis of, causes of, 419 

symptoms and signs of, 420 
Arterio-capillary fibrosis (see Arteries, 

sclerosis of). 
Artery, tension of, causes of, 185 

recognition of, 186 
Arthritis, rheumatoid, acute, 710 
chronic, 711 
diagnosis of, 712 
hand in, 127, 712 
pulse in, 375, 711 
senile form of, 712 
skin in, 711 
Articulation, occipito-atlantal, tuberculosis 

in, 121 
Ascites, 578 

in general enlargement of abdomen, 
471 

Aspiration, 159 

of body cavities, 160 
Asthma, 302 

dyspnoea in, causes of, 285 
Atavism, 28 
Ataxia, 792 
febrile, 107 
hereditary, 830 
Ataxic state, 107 

in acute diseases, 108 
Atelectasis, 326 
Athetosis, 131, 791 
Atrophy, optic, 807 

progressive muscular, 831 

hand in, 127 
simple idiopathic muscular, 832 
Auscultation (see Chest), 
general section on, 53 

BACILLI, 149 
comma (see Spirilla), 
of Booker, 547 
Bacillus, anthrax, 775, 165 
in blood, 703 
coli communis, 162, 166, 544 
comma, 545 
Eberth's, 731 
Klebs-Loffler, 757 
leprae, 778 
Lather's, 453 
of glanders, 165 

in blood, 703 
of influenza, 166 

in sputum, 281 
of syphilis, 164 
of tetanus, 166 
tubercle (also see Sputum), 
in faeces, 547 
in blood, 701 
typhoid fever, 547 
Backache, 48 

in fevers, 108 
Bacteria, 147 

cultivation of, 154 

determination of specific nature of, 157 
in pus, 161 



INDEX. 



863 



Bacteria in the saliva, 432 

pyogenic, 162 
Bacteriology, apparatus necessary in, 151 
preparation of, 151 

collection of material in, 152 

cover-glass preparations in, 153 

culture media in, 154 

"hanging-drop" in, 154 

inoculation of animals in, 157 

Koch's laws in, 146 

methods of research in, 146, 150 
of staining in, 153 

preparation of cultures in, 156 

special diagnosis in, 157 

sterilization in, 151 
Bacteriuria, 660 
Bell-tympany, 262 
Bile-ducts, cancer of, 604 
Biliousness, 585 
Blindness, functional, 807 
Blood, alterations in, 172 

counting corpuscles of, 685 

cover-slip preparations of, 152 

estimation of haemoglobin of, 683 

in gastric contents, tests for, 489 

in leucocythsemia, 694 

in stools, in diarrhoea, 530 

naked-eye appearances of, 683 

parasites in, 701 

pressure, 185 

proportion of red to white corpuscles 
of, 683 

Body, general form and nutrition of, 61 
Bones in general diagnosis, 139 

nodes on, 139 
Boulimia, 503, 515 
Bradycardia, 375 
Brain, abscess of, 841 

acute softening of, 841 
anaemia of, 836 
hyperaemia of, 837 
lobes of, 799 

occipital, 799 
parietal, 799 
prefrontal, 797 
localization of areas, 795 
softening of, 839 
tumors of, 842 

distinguished from meningitis, 
836 _ 

Brawny induration, 98 
Breakfast, test, 490, 491 
Breath, fcetor of, in pharyngeal affections, 
454 ( 

Breathing, alteration of the rhythm in, 255 
bronchial, 253, 256 

in pleurisy, 330 

varieties of, 257, 258 
broncho-vesicular, 254, 258 
feeble, 254 

jerking inspiration in 256 . 
prolonged expiration in, 256 
puerile, 254 
vesicular, 253 

diminished or absent, 255 



Breathing, vesicular, exaggerated, 254 
Bright's disease, acute rhinitis in, 188 
anidrosis and boils in, 77 
erythema in, 88 
facies in, 118 
Bronchi, dilatation of, 300 

diseases of, recognition of, 294 
obstruction of, 302 
Bronchiectasis, 300 
Bronchitis, acute, 295 • 
capillary, 297 

chronic, diseases with which associated, 
298 

collapse of lung in, 326 
fibrinous, casts in, 272 
foetid or putrid, 299 
plastic, 299 
specific, 300 
Brown ian movement, 154 



C~ ACHEXIA in gastric cancer, 508 
malarial, 770 
of carcinoma, 183 
Cachexiae, varieties of, 56 
Caecum, diseases of, palpation and percus- 
sion in, 475 
faecal impaction of, 476 
Calculus, renal, 679 
Cancer [see Carcinoma). 
Capsule internal, lesions of, 800 
Carbuncle distinguished from anthrax, 776 
Carcinoma, cachexia of, 183 
facies of, 118 

gastric, supra-clavicular glands in, 134 

hemorrhagic exudation of, 167 

metastasis in, 183 

symptoms of, 182 
Cardialgia, 501 
Case records, 21 

plan for recording, 22 
Casts, fibrinous, in plastic bronchitis, 299 
Catalepsy, 792 

Catarrh, chronic post-nasal, 197 

nasal {see Rhinitis). 

suffocative, 297 
Cavities, pulmonary, 263 
Cavity, pulmonary, distinguished from 

pneumothorax, 337 
Cerebellum, disease of, 803 
Cerebral disease, vomiting in, 500 
Chest, adenoid disease of, 236 

angles of, 227 

auscultation of, aegophony in, 263 
bell-tympany in, 262 
friction sound in, 261 
metallic tinkling in, 261 
methods of, 252 
pectoriloquy in, 263 
position of patient in, 252 
pulmonary cavities in, methods of 

determining, 264 
rales in, 259 

sounds in disease in, 254 
in health in, 253 



864 



INDEX. 



Chest, auscultation of, stethoscope in, 252 
succussion in, 262 
vocal resonance in, 262 
" barrel-shaped," 232 
in adenoid vegetations of naso- 
pharynx, 458 
inspection of, 230 
lines of, 227 

local changes in size and shape of, 238 
mensuration of, 265 
movements of, 231 
in disease, 238 
percussion of, amphoric or metallic 
sounds in, 251 
auscultatory or stethoscopic, 247 
cracked-pot sound in, 251 
dulness in, 246, 250 
methods of, 244 
object of, 248 
pitch in, 247, 249 
pleximeter in, 244 
plessor in, 244 
position of patient in, 245 
resistance in, 247 
resonance in, 245, 248 
superficial and deep, 247 
tympany in, 246, 250 
phthisical, 234 
rhachitic, 235 
regions of, 226 
shape and size of, 230 
topographical anatomy of, 228 
unilateral changes in shape of, 237 
Chiasm, optic, diseases of, 807 
" Chicken-breast," 187 
Chlorosis, 691 

venous hum in, 384 
Cholera, 760 

Asiatic, spirillum of, 150 
bacterial diagnosis of, 761 
erythema in, 88 
facies in, 118 
infantum, 550 
morbus, 556 

distinguished from cholera, 761 
nostras, 557 

spirillum of, 150 
tongue in, 447 
Chorea, 845 

paralytic, 846 
Choreiform movements, 791 
Chyluria, 659 

parasitic, 660 
Circulation, local disturbance of, 172 
Cloudy swelling in fever, 106 
Coin test in pneumothorax, 336 
Colic, 469 ^ 

hepatic, 526, 615 
intestinal, 525 

conditions from which it must be 
distinguished, 526 
lead, 526 
pancreatic, 502 
renal, 526 
uterine, 527 



Collapse, 116 

perspiration in, 76 
Colon, dilatation of, 573 

in general enlargement of abdo- 
men, 471 
| Coma, diabetic, 668, 718 

ursemic, 667 
j Comedones, 121 

' Concussion confounded with shock of hem- 
orrhage, 177 
Congestion {see Hyperemia). 
Conjunctiva, color of, 124 
Constipation, 532 

secondary effects of, 533 
Constitution, section of, 55 
j Contractures, hysterical, 851 
Convulsions, 792 {see Fits). 

epileptiform, 791 

hysterical, 852 

ursemic, 667 
Cord {see Spinal cord). 
Cords, vocal, paralysis of, 816 
Corpora quadrigemina, disease of, 801 
Corpus callosum, disease of, 799 

striatum, 800 
j Coryza, acute, 194 

headache in, 856 

syphilitic, 197 
Cough, diagnostic significance of, 290 

dry, 289 

due to enlarged uvula, 452 
in aortic aneurism, 424 
in carcinoma of oesophagus, 464 
in disease of heart, 390 

of nose, 189 
in ear disease, 289 
in laryngeal affections, 204 
in mediastinal diseases, 429 
in oesophageal affections, 461 
in phthisis, cause of, 288 
in pleurisy, 333 
in pulmonary affections, 288 
in tuberculosis, 323 
moist, 290 

of centric origin, 289 
of nervous origin, 205 
reflex, 224 
stomach, 289 
tooth, 289 
winter, 298 
Coxalgia, distinguished from appendicitis, 
571 

Cracked-pot sound, 251 
Cramp, writer's, 848 
Cramps in calves in uraemia, 667 
Cranio-tabes, 68, 121 
Cranium, fontanelles of, 121 

murmur heard over, 381 
Crises in locomotor ataxia, 829 
Croup, false, 210 

membranous, 209 
Cms cerebri, disease of, 801 
Crystals, 539 

Charcot-Leyden, 272, 274 
in nasal secretions, 194 



INDEX. 



865 



Crystals in pus, 167 
Cyanosis, causes of, 72 

in acute miliary tuberculosis, 318 

in congenital heart disease, 419 

in emphysema, 304 
Cysticercus cellulosae, 99 
Cysts, exploratory puncture of, 160 

hydatid, fluid of, 168 

ovarian, 169 

uric acid in, 170 

pancreatic, 170 

DECUBITUS, 57 
Degeneration, reaction of, 795 
Delirium in uraemia, 666 
Diabetes insipidus, 719 
mellitas, 717 

cataract in, 719 
complications of, 718 
neuralgia in, 855 
tongue in, 447 
Diaceturia, 648 
Diagnosis, etiological, 18 
bacteriological, 145 
conditions may render impossible, 19 
data upon which based, 18, 24, 49 
electrical, 793 
general observations on, 17 
instruments necessary in, 54 
methods of, 19 
modern methods of, 20 
object of, 18 

objective symptoms in, 49 

method of observing, 51 
requisite knowledge for making, 18 
should be complete, 20 
temperament and constitution in, 55 
value of scars in, 77 
Diarrhoea, uraemic, 668 
chronic, 531 
membranous, 532 

microscopical and bacteriological ex- 
amination of stools in, 530 
symptoms of, 530 
Diatheses, varieties of, 55 
Diphtheria, 755 

distinguished from follicular tonsilli- 
tis, 456, 
laryngeal, 209 
Diplococci, 148 

Diplococcus pneumoniae (see Micrococcus 

lanceolatus). 
Disease, blue, 419 

foot and mouth, 776 

Meniere's, 815 

mimicry in, 32 

present, importance of order of events 
in, 30 

method of eliciting facts in, 29 
previous, as a factor in diagnosis, 
29 

Thomsen's, 137, 832 
vagabond's, 74 
vertebral, pain in, 46 



Diseases, acute infectious, dilatation of 
heart in, 417 
classification of, 23 
feigned, 32 
infectious, 723 

erythemata in, 87 
remarks on diagnosis of, 785 
roseola in, 87 
Dropsy (see (Edema). 

in nephritis, 669, 672 
Drugs, rashes caused by, 86 
Duodenum, catarrh of, 549 
Dupuytren's contraction, 130 
Dysentery, acute, 551 
amoebic, 552 

diagnosis of, 556 
hepatic abscess in, 555 
peritonitis in, 556 
symptoms of, 552, 555 
catarrhal, 551 
Dyspepsia, atonic, 519 
flatulent, 520 
nervous, 519 
uterine, 521 
Dysphagia in diseases of oesophagus, 463 

in laryngeal affections, 204 
Dysphonia, 204 
Dyspnoea, asthmatic, 285 
causes of, 282 
clinical varieties of, 287 
diagnosis of, 288 
due to enlarged uvula, 452 
from diminished pulmonary air-space, 
284 

from muscular inaction, 286 

heat, 282 

hysterical, 852 

in aortic aneurism, 424 

in bronchial obstruction, 284 

in cardiac disease, 390 

in diseases of mediastinum, 429 

in nephritis, 672 

in pharyngeal affections, 454 

in tracheal obstruction, 283 

in tuberculosis, 323 

laryngeal, 202 

distinguished from other forms 
of, 203 

movements in, 125 
of emphysema, 288 
phrenic, 286 
reflex, 224 

spasmodic, in interstitial nephritis, 677 
uraemic, 667 
Dystrophies, connective-tissue, 97 



EAR, diseases of, cough in, 289 
in general diagnosis, 124 
tophi in, 125 
Earache in suppurative tonsillitis, 456 
Eczema distinguished from varicella, 742 
Effusions, specific gravity in, 168 
Electrical diagnosis, 793 
Elephantiasis, chyluria in, 135 



866 



INDEX. 



Embolism, 174 
cerebral, 841 
in arterial sclerosis, 420 
kinds of, 175 

pulmonary, symptoms of, 175 
Embryocardia, 359 

in dilatation of heart, 419 
Emphysema, 303 

adventitious sounds in, 305 

atrophic, 305 

distinguished from pneumothorax, 336 
dyspnoea of, 288 
heart in, 305 
interlobular, 305 
subcutaneous, 97 
Empyema, Bacelli's sign in, 331 
causes of, 329 
in abscess of liver, 611 
peptonuria in, 331 

points of spontaneous discharge of, 
331 _ 

pulsating, confounded with aneurism, 
428 m 

Endocarditis; chronic, 402 

malignant, 400 

mycotic aneurism in, 421 

simple, 399 
Enteralgia, 525, 526 

Enteritis distinguished from intestinal 

obstruction, 566 
Entero-colitis, 550 

confounded with peritonitis, 577 
Enuresis in adenoid vegetations of naso- 
pharynx, 458 
Epiglottis, inflammation of, 210 

tuberculosis of, 218 
Epilepsy, 849 
Epistaxis, causes of, 194 

in interstitial nephritis, 676 
Eruptions, skin, factitious, 88 

traumatic, 89 
Erysipelas, 758 
Erythema, aetiology of, 84 

character of eruption in, 84 

classification in, 83 

in infectious diseases, 85 

kinds of, 84 

lseve, 85 

medicinal, 86 

multiforme, 84 

nodosum, 86 

of infectious diseases, 87 

vesicular, 85 
Erythromelalgia, 132, 173 
Exudations, 161, 167 

chylous, 168 

serous, 168 



'ACE, enlargement of, 120 
expressions of, 117 
hemiatrophy of, 119 
in children, 118, 119 
in nephritis, 65 
in nervous diseases, 119 



Face, local affections in skin of, 121 
Facial expression in pain, 35 
Facies, Hippocratic, 119 

in various diseases, 118 
Faeces, bacilli of Booker in, 547 

bacteria in, 544 

blood in, 536 

-corpuscles in, 538 

chemical examination of, 547 

crystals in, 539 

epithelium in, 538 

fat and pus in, 537 

gall-stones in, 536 

general section on, 535 

microscopical examination of, 537 

moulds and yeasts in, 544 

mucus in, 537 

protozoa in, 539 

spirillum of cholera nostras in, 546 

tubercle bacillus in, 547 

typhoid fever bacillus in, 547 

vermes in, 541 
Family history in aetiology of disease, 27 
Farcy, 773 

Fauces (also see Pharynx). 

examination of, 451 
Feet, cold, 133 

Fehhng's solution, preparation of, 644 
Fermentation, putrefactive, 149 
Fever (see Temperature). 

acute specific, 723 

" break-bone," 763 

cerebro-spinal, 753 

clinical causes of, 110 

course of, 104 

crisis in, 104, 105 

definition of, 99 

determination of, 100 

fastigium in, 104, 111 

general causes of, 99 

hay, 200, 300 

hectic, 178 

hemorrhage into skin with, 78 

hepatic, 594 

high, dangers in, 102 

hysterical, 851 

in gastric cancer, 508 

intermittent, hepatic, 114, 595 

irregular forms of, 765 

malarial, 763 

type of, diseases in which it may 
occur, 113 

urinary, 113 
in tuberculosis, 321 
lysis in, 104, 105 
malarial, 763 
miliary, 779 

modes of onset in, 105, 111 
nervous, ] 11 
pernicious malarial, 769 
relapsing, 736 

spirillum of, 701 
remittent malarial, 768 
rheumatic, 705 
scarlet, pulse in, 374 



INDEX. 



867 



Fever, significance of age and sex in, 115 
simple continued, 785 . 
symptoms of, 106 

syphilitic, distinguished from inter- 
mittent, 768 
types of, 102, 112 

continued, 115 

remittent, 114 
typhoid, acute bronchitis in, 296 

ambulatory, 730 

Baruch's diagnostic sign of, 732 

bilious, 738 

conditions with which confounded, 
733 

diagnosis of, 732 
. diazo-reaction of urine in, 727 
distinguished from acute miliary 
tuberculosis, 318 
from influenza, 752 
from malignant endocarditis, 
401 

from pernicious malarial, 
770 

Eberth's bacillus of, 731 
eruption in, 729 
facies in, 118 
fsecal impaction in, 534 
inflammation of parotid in, 461 
mode of invasion in, 724 
necrosis of sternum in, 139 
nervous symptoms in, 727 
period of incubation in, 724 
pulse in, 374, 727 
puncture of spleen in, 161 
spleen in, 725 
symptoms of, 724 
temperature in, 725 
varieties of, 730 
typhus, 734 

cerebro-spinal, distinguished from 
736 

conjunctivitis in, 124 
yellow, 770 
Filaria sanguinis hominis, 704 
Fingers, abnormal shape of, causes of, 
131 
tophi in, 130 
Fits, 116 

Flagellae, staining of, 154 
Flat-foot, pain in, 45 
Flatulency in gastric affections, 501 
Flushings, significance of, 34 
Fontanelles (see Cranium). 
Food, regurgitation of, in gastric neuroses, 
519 

Foot, Morton's painful affection of, 45 

tabetic, 142 
Fremitus, friction, 243 

vocal, in disease, 242 
in health, 241 
Friction, peritoneal, 475 

pleural, 261 

pleuro-pericardial, 394 
Friedreich's sign of cavity, 264 
Fungi in saliva, 432 



GAIT and attitude in general diagnosis, 
57 

and station in various nervous affec- 
tions, 60 
Gall-bladder, cancer of, 618 

enlargement of, confounded with float- 
ing kidney, 617 
inflammation of, 616 
topographical anatomy of, 597 
tumors of, 616 
Gall-ducts, gall-stones in, 615 
obstruction of, 616 

by gall-stones, 618 
stenosis of, symptoms, 619 
Gall-stones, accidents of, 618 

in gall-ducts, 615 
Gangrene, 179 

of internal organs, 180 
Gastralgia, hysterical, 517 

in disease of central nervous system, 
516 

in morphinism, 44 
neurasthenic, 517 
pain of, 502 
Gastrectasia, 512 
Gastritis, acute, 504 

in onset of various diseases, 505 
pain in, 503 
vomiting in, 498 
chronic, 506 

dry mouth in, 430 

tabulated diagnosis from gastric 

ulcer and cancer, 510 
vomiting in, 499 
mycotic and diphtheritic, 506 
phlegmonous, 505 
toxic, 505 
Gastrodynia, 501 
Gastroxynsis, 518 

General paralysis of the insane, face in, 119 
Gerhardt, " complemental space" of, 228 
Gerhardt's sign of cavity, 264 
Gingival line, 434 

Gland, parotid, inflammation of, 461 
Glands, lymphatic, ingeneral diagnosis, 134 
Glanders, 773 
nasal, 198 
Globus hystericus, 202 
Glossitis, acute, 439 

chronic superficial, 440, 443 
dissecting, 441 
hemi-, 440 
Glycosuria in disease of pancreas, 623 
Goitre, exophthalmic, 700 
eye in, 123 
facies in, 118 
pulse in, 374 
Stellwag's sign in, 123 
Von Graefe's sign in, 123 
Gonococcus, 166 
Gout, 713 

abscesses in, 714 
chronic, 714 

distinguished from rheumatoid arthri- 
tis, 712 



868 



INDEX. 



Gout, Dupuytren's contraction in, 130 
dyspepsia in, 522 
joint of, 142 

relation to lithaemia, 586 

retrocedent, 714 
Gram's method, 154 
Granulomata, infective, 723 
Graves' disease (see Goitre). 
Gums in lead- poisoning, 434 

in scurvy, 434 



H^MATEMESIS, 495 
Haematidrosis, 721 
Hematocele, pelvic, 476 
Haematokrit, 687 
Hematoma auris, 125 
Hemocytometer, Gowers', 685 

Thoma-Zeiss, 686 
Hemoglobinoineter, Fleischl's, 684 

Gowers', 683 
Hemoglobinuria, 644 
paroxysmal, 644 
Haemophilia, 79, 719 

conditions with which confounded, 720 
degrees of, 720 
joint symptoms in, 720 
Haemoptysis, 269 
causes of, 291 
diagnosis of, 293 

distinguished from hematemesis, 495 

in the invasion of chronic tuberculosis, 
319, 323 

symptoms of, 292 
Hemothorax, 332 
Hair in diagnosis, 120 
Hand, claw-, 127, 130 
Hands, cold, 133 
" Hanging drop," 154 
Harrison's groove (see Rhachitis). 
Hay fever, 300 
Headache, "blind," 501 

carious teeth, cause of, 435 

character of pain in, 859 

chronic, 858 

congestive, 859 

duration of, 859 

in fevers, 108 

in inflammation of cranial bones, 857 

in interstitial nephritis, 675 

in lithaemia, 585, 586 

in meningitis, 834 

in scalp affections, 854 

in uraemia, 666 

ocular, 855, 859 

organic, 859 
Hearing impaired by drugs, 125 

tests for, 125, 814 
Heart, accentuation of aortic second sound 
of, 357 

of pulmonary second sound of, 358 
action of, 340 

alterations of rhythm of, causes of, 342 
anatomy of, 338 
aneurism of, 404 



Heart, apex beat of, 339, 343, 353 
absent, 345 
displaced to left, 344 
to right, 345 
area of deep dulness of, 350 

of dulness, method of graphic 

record, 353 
of impaired resonance over, 339 
of superficial or absolute dulness 
of, 348 
changes in size of, 349 
arrhythmia of, 389 
auscultation of, 354 
bovine, in aortic insufficiency, 405 
cantering rhythm of, 360 
chronic valvular disease of, 404 
combined valvular lesions of, 414 
congenital disease of, 419 
dilatation of, 417 

definition of, 414 
in nephritis, 668 
murmurs in, 419 
disease of, cerebral symptoms in, 390 
cough in, 390 
decubitus in, 58 
gastric symptoms in, 391 
general symptomatology of, 340 
inspection in, 343 
kidneys in, 391 
laryngeal symptoms in, 391 
palpation in, 346 
percussion in, 348 
pleximetric percussion in (see 

Pleximeter) . 
praecordia in, 343 
pulse in, 375 

tracings of, 379 
retraction of interspaces in, 346 
thrills in, 347 
tongue in, 448 
fatty degeneration of, symptoms of, 
403 

overgrowth of, symptoms of, 404 
feebleness of mitral sound of, 359 

of pulmonary sound of, 359 
first sound of, accentuated, 357 
foetal rhythm of, 359 
hypertrophied, epigastric pulsation 

in, 369 
hypertrophy of, 414 

causes of, 414 

diagnosis of, 417 

in arterial sclerosis, 420 

in nephritis, 668 

of auricles of, 415 

of left ventricle of, 415 

of right ventricle of, 415, 416 
impulse of, 344, 345 

character and strength of, 346 

new causes of, 346 
in lithaemia, 586 
murmurs, causes of, 362 

changes in, 366 

character of, 365 

diagnosis of, 363 



INDEX. 



869 



Heart murmurs, direction of transmission 
of, 363, 365 
in anaemia, 366 

in incompetency of heart valves, 
366 

in valvular disease, 362 
position of maximum intensity 
of, 363 

secondary effect on, and on pulse, 
of valve lesions, 367 

significance of, 366 

time of, 364 
outline of, on chest wall, 338 
pain in disease of, 387 

in region of, 385 
palpitation of, 388 

in interstitial nephritis, 676 
reduplicated sounds of, diastolic, 361 

systolic, 360 
rupture of, 404 

second aortic sound of, in arterial 

sclerosis, 420 
sounds of, all increased, 357 

all weakened, 357, 359 

character of, 356 

differentiation of, 357 

in health, 354 

seat of origin and transmission, 
355 

systolic and diastolic, differentia- 
tion of, 356 

valves of, position of, 339 
shock of, 347 

valvular disease of, dropsy in, 390 
dyspnoea in, 390 
gastric catarrh in, 522 
hemorrhage in, 389 
Heartburn (see Pyrosis). 
Heberden's nodes, 130 
Hectic fever, facies in, 118 
Heel, pain in, 45 
Hemianesthesia hysterica, 851 
Hemianopia, 808 

Wernicke's sign of, 808 
Hemicrania, 857 
Hemiplegia, infantile, 840 

nails in, 133 
Hemorrhage, 175 

cerebral, 837 

in aortic aneurism, 424 

in cirrhosis of the liver, 605 

in hysteria, 851 

in leucocythaemia, 694 

in splenic leukaemia, 621 

internal symptoms of, 176 

into skin, 77 

meningeal, 822, 839 

pancreatic, 623 

parenchymatous, 176 
Heredity in aetiology of disease, 27 

in haemophilia, 79 

in neuroses, 28 

in syphilis, 28 

method of eliciting facts in, 27 
Herpes labialis, 85 



Herpes of fifth nerve, 85 

pain in, 85 

zoster, 85 

distinguished from erysipelas, 759 
Hiccough in gastric affections, 504 

in uraemia, 668 
Hodgkin's disease, 696, 697 

distinguished from scrofulous 
glands, 698 
Hydrocephalus, 122 

chronic, 844 
Hydrochloric acid in gastric cancer, 509 
Hydronephrosis, 631, 679 
Hydrophobia, 777 
Hydrothorax, 332 
Hyperaemia, 80 

causes of, 172 
Hyperidrosis, 75 
Hyperorexia, 515 
Hyperpyrexia, 102 
Hysteria, 850 

distinguished from meningitis, 836 

flatulency in, 501 

joint of, 143 
Hysterical attacks, 852 
Hystero-epilepsy, 853 



IMPETIGO distinguished from varicella 
742 m 

Indican in intestinal obstruction, 564 

in urine, in suppuration, 178 
Indigestion in children, in adenoid vege- 
tations of naso-pharynx, 458 

intestinal, 547 
Infarct, hemorrhagic, 175 
of uvula, 452 
Inflammation, 177 

specific, 723 
Influenza, 751 

erythema in, 88 
Inspection, general section on, 51 

systematic, of a patient, 55 
Intestinal obstruction, acute, tongue in, 
447 

confounded with acute hemor- 
rhagic pancreatitis, 624 
Intestines, acute catarrh of, 548 
amyloid degeneration of, 573 
arteries of, emboli of, 525 
cancer of, 572 
chronic catarrh of, 557 
diseases of, 523 

constipation in, 532 
diarrhoea in, 528 
subjective symptoms of, 525 
disorders of, in other diseases, 525 
hemorrhage of, 534 
hernia and volvulus of, course of, 565 
infarction of, 573 
intussusception of, 564 
obstruction of, acute, 559 

differential diagnosis in, 563 
causes of, 560 
urine in, 564 



870 



INDEX 



Intestines, obstruction of, chronic, 562 

conditions with which confound- 
m ed, 565 

distinguished from peritonitis 565, 
577 

symptoms of, 561 
organic disease of, confounded with 

colic of, 528 
symptoms of worms in, 524 
tuberculosis of, 572 
ulceration of, 557 
general, 558 
volvulus of, 559, 565 
Intussusception, 476, 559, 564 
Iris, actions of, 810 

paralysis of, 811 
Itching in skin eruptions, 82 

JAUNDICE, acute febrile, 595 
catarrhal, 614 
concomitant symptoms of, 71 
fever in, 594 
haematogenous, 592 

distinguished from hepatogenous, 
593 

hepatogenous, 592 
infantile, 593 

in tumors of pancreas, 623 
malignant, 594 

obstructive, diagnosis of cause of, 592 

skin in, 71 

symptoms of, 591 
joint of synovitis, 141 

tabetic, 142 
Joints, affections of, distribution in, 144 

diagnostically important, 143 

enlarged, general causes of, 140 

examination of, 144 

hysterical, 143 

KIDNEY, abscess of, 631, 677 
alterations of functions, symptoms, 628 
amyloid degeneration of, 678 
congestions of, 670 
cystic, 170, 678 
degenerations of, 677 
diseases of, classification, 628 

frequency of micturition in, 629 
general section on, 627 
pain in, 629 
enlargements of, causes of, 631 
exploratory puncture of, 161 
floating, 632, 681 

confounded with enlarged gall- 
bladder, 61 7 _ 
granular or cirrhotic, 674 
horseshoe, 679 
malignant tumors of, 633 
neuralgia of, 629 
palpation and percussion of, 630 
parasites in, 680 
sarcoma and carcinoma of, 678 
Kidneys (also see Urine). 
Koch's laws, 146 



T ANDEY'S paralysis, 827 
L Laryngismus stridulus, 213 
Laryngitis, acute, 208 

with spasm, 210 
with stenosis, 209 
chronic, 212 
phlegmonous, 212 
sicca, 209 
spasmodic, 210 
submucous, 212 
Laryngoscopy, 206 
Larynx, anaemia of, 208 

appearance of, in health, 207 
diseases of, 200 

conditions confounded with, 201 
general symptoms in, 205 
sputum in, 207 
symptoms of, 201, 205 
table of, 211 
foreign bodies in, 220 
hyperemia of, 208 
in nervous affections, 220 
in paralysis of recurrent laryngeal 

nerve, 215 
lepra of, 220 
lupus of, 219 

muscles of, paralyses of, 214 
neuroses of, 213 
oedema of, 210 
spasm of, 816 
syphilis of, 218 
tuberculosis of, 216 

distinguished from syphilis of, 218 
tumors of, 215 
Lavage, 488 

Lead-poisoning, gums in, 434 
Leptomeningitis, cerebral, 834 
Leptothrix buccalis, 434 
Leucocythaemia, 693 

blood in, 694 

cover-glass preparations of, 695 
staining of, 695 

diagnosis of, 696 

duration of, 697 

splenic, 694 

varieties of leucocytes in, 695 
Leucocytosis, 688 
Leucoderma, 98 

Leukaemia, splenic, diagnosis of, 621 
Leprosy, 778 

bacillus of, 165 
Lineae albicantes, 473 
Lipomatosis, 180 
Lips in diagnosis, 123 
Lipuria, 659 

Lithaemia, acute and chronic, 585 

headache in, 855 
Liver (also see Jaundice), 
abscess of, 596, 608 

confounded with enlarged gall- 
bladder, 617 
empyema in, 611 
exploratory puncture in, 611 
acute yellow atrophy of, 594 
amyloid disease of, 596, 601 



INDEX. 



871 



Liver, aspiration of, 598 
cancer of, 597, 602 
cirrhosis of, 604 
atrophic, 604 
biliary, 607 

collateral circulation in, 606 

diagnosis of, 607 

hemorrhage in, 605 

hypertrophic, 603, 607 

symptoms and signs of, 605, 606 

syphilitic, 607 
collateral circulation in portal obstruc- 
tion, 589 
congenital syphilis of, 608 
constriction of, from lacing, 597 
diseases of, age in, 589 

pain in, 45, 590 

previous affections in, 590 

sex and habits in, 590 

stomach in, 522 
enlargement of, causes of, 599 

pain in, 601 

simulated, 599 
exploratory puncture of, 160 
fatty, 596, 601 
floating, 597 

functional disturbances of, symptoms 
of, 584 

hydatid disease of, 596, 012 

multilocular, 617 
hyperemia of, 587 
hypertrophic cirrhosis of, 597 
in affections of portal vein, 588 
morbid processes in, symptoms of, 584 
obstruction of channels of, 587 
palpation of, 596 
percussion of, 598 

pulsation of, in tricuspid insufficiency, 
413 

symptoms of portal obstruction in, 588 
syphilitic gummata in, 608 
topographical anatomy of, 590, 598 
Locality, sense of, 787 
Locomotor ataxia, 828 

cephalic crises in, .856 
crises in, 43 

distinguished from multiple scle- 
rosis, 843 
gait in , 60 

gastric crises in, 516, 521 
joints in, 142 
station in, 61 
Lumbago, 710 
Lung, abscess of, 326 

apical consolidation of, subclavian 

murmur in, 381 
collapse of, 326 
gangrene of, 325 
hydatid disease of, 328 
new growths of, 327 
Lungs (also see Chest). 

affections of, reflex vomiting in, 500 
and pleurae, diseases of, cough in, 288 
dyspnoea in, 282 
hemorrhage in, 291 



Lungs and pleurae, diseases of, pain in, 293 
without dyspnoea, 282 
capacity of, measurement of, 265 
cavities of, 263 
congestion of, 306 
diseases of, classification of, 222 

combination of physical signs ob- 
tained in, 266 
diagnosis of, 225 
friction sound in, 261 
inspection and palpation in, 226 
palpation in, 241 
percussion in, 243 
rales in, 259 

relation of heart to, 224 

of infectious diseases to, 225 
respiration in (see Breathing), 
rhonchi in, 243 

subjective and objective symptoms 
in, 225 

symptoms due to external causes 
in, 223 
to morbid processes in, 
223 

vocal fremitus in, 242 
embolism and thrombosis of, 307 
gangrene of, distinguished from foetid 

bronchitis, 300 
hemorrhagic infarcts of, 307 
oedema of, 306 

topographical anatomy of, 228 



MCBUKNEY'S point, 568 
Microglossia, 443 
Malaria (a/ so see Fever), 
facies in, 118 
hemidrosis in, 76 
neuralgia in, 856 
Plasmodia of, 702 
staining of, 703 
Malingerer, 32, 37 
Marasmus, 62 
Measles, 742 

distinguished from scarlatina, 748 

from varioloid, 741 
eruption of, in pharynx, 450 
Mediastinum, cancer of, confounded with 
aortic aneurism, 428 
diseases of, 428 
Medulla oblongata, lesions of, 803 
Melanaemia, 688 

Membranes, inflammation of, 179 
Meniere's disease, 61, 815 
Meninges, tumors of, 842 
Meningitis, chronic, 836 

cerebro-spinal, distinguished from in- 
fluenza, 752 
distinguished from typhoid fever, 733 
purulent, 836 
spinal, 820 

chronic, 821 
syphilitic, 821, 836 
tubercular, 834 

conjunctivitis in, 124 



872 



INDEX, 



Meningitis, tubercular, distinguished from 

simple form, 835 
Metallic tinkling, 336 
Micrococci, 148 

Micrococcus lanceolatus, 162, 166 

in pleural effusion, 168 

in sputum, 280 

staining of, 280 
Microcythaemia, 688 

Micro-organism (see Bacteria or Bacteri- 
ology). 

Microscope, diaphragm of, use of, 152 
Micturition, frequent, causes of, 629 
Migraine, 857 
Miliaria, 88 
Milk sickness, 779 
Mitral incompetency, 407 

bloodvessels in, 410 

broken compensation in, symp- 
toms of, 409 

diagnosis of, 410 

effects of, upon the circulation, 
408 

other valvular murmurs in, 410 

physical signs of, 409 

thrill in, 348 
stenosis, 410 

associate murmurs in, 412 

physical signs of, 411 

presystolic thrill in, 347 
Morbid processes, 171 

in tubes or channels, 184 

symptomatology of, 171 
Morphinism, pain in, 36, 44 
Motility, disturbance of, 790 
Mouth, diseases of, 430 
dry, 430 

eruptions in, in infectious diseases, 
431 

inflammation of (see Stomatitis). 

secretions of (see Saliva). 

ulcers of, herpetic, 438 
syphilitic, 438 
Mumps, 753 

face in, 120 
Murmur (see Heart). 

in disease of arteries, 382 

functional or haemic, 381 

pressure, 381 

respiratory, 253 
Muscles, atrophy of, 135 
primary, 136 
Raymond's table of, 138 

hypertrophy of, 137 

lack of tone in, 115 

ocular, spasm of, 813 

progressive ossification of, 138 

pseudo-hypertrophy of, 135 
Myelitis, 823 

acute transverse, 824 

disseminated, 824 

central, 825 

chronic, 825 
Myocarditis, 402 
Myositis, 138 



Myotonia congenita, 137 

Myxoedema, 96 

dry skin in, 77 
outline of face in, 66 



NAILS, shape and color of, 132 
trophic changes in, 133 
Naso-pharynx, adenoid vegetations of, 457 

affections of, in children, 450 
Nausea in gastric affections, 496 
Neck in general diagnosis, 125 
Necrosis, 179 

Nephritis (also see Uraemia), 
acute exudative, 671 

with excessive pus, 672 
occurring with tonsillitis, 455 
productive or diffused, 672 
anaemia in, 670 

cardio -vascular symptoms of, 668 
chronic productive, with exudation, 
673 

course of, 674 
without exudation, 674, 676 

apoplexy in, 676 

gastro-intestinal symp- 
toms in, 670 

heart in, 675 

inflammation of serous 
membranes in, 676 

neuro-retinitis in, 676 

pulmonary symptoms in, 
675 

uraemia in, 675 

urine in, 674 
classification of, 671 
dropsy in, 669 
face in, 669 

gastric symptoms in, 522 
hemorrhages in, 669 
in scarlatina, 747 
interstitial, 674 

ophthalmoscopic changes in, 669 
petechias in, 670 
suppurative, 677 
tubercular, 677 
Nephrolithiasis, 679 

Nerve, recurrent laryngeal, paralysis of, 
215 

Nerves, diseases of auditory, 814 

of fifth, 811 

of fourth, 811 

of glosso-pharyngeal, 815 

of hypoglossal, 817 

of laryngeal, 815 

of oculo-motor, 810 

of olfactory. 806 

of optic, 806 

of pneumogastric, 815 

of seventh, 813 

of sixth, 812 

of spinal accessory, 817 
Neuralgia, 789 

carious teeth, cause of, 435 
cephalic, 855 



INDEX. 



873 



Neuralgia, intercostal, 385 

distinguished from pleurisy, 334 
lumbo-abdominal, confounded with 

intestinal colic, 528 
of kidney, 629 
of nerves of scalp, 855 
of spinal nerves, 818 
trifacial, 812 
Neurasthenia, 853 

Neuritis confounded with joint affections, 
141 

multiple, 819 

nails in, 133 

of brachial plexus, 818 

of spinal nerves, 817 

optic, 807 

peripheral, in diabetes mellitus, 718 
wrist-drop in, 128 
Nigrities, 439 
Nodules, subcutaneous, 99 
Nose, auxiliary cavities of, disease of, 199 
in adenoid vegetations of naso-pha- 

rynx, 457 
deformity of, 190 
disease of (see also Rhinitis), 
asthma in, 200 

color of mucous membrane in, 192 

rhinoscopy in, 191 

symptoms of, 187 

ulceration of mucous membrane 
in, 193 

ulcerative, 199 
foreign bodies in, 198 
polypi of, 198 
tumors of, 198 
Nystagmus, 811 



OBESITY in general enlargement of 
abdomen, 470 
Occupation in aetiology of disease, 25 
(Edema, angio-neurotic, 95 
anthrax, 775 
causes of, 92 

combined, 96 
conditions with which confounded, 93 
definition of, 92 
general, 95 
local, 94 

of arms and thorax, 94 
of face, 94 
of feet, 94 
of larynx, 210 

in angio-neurotic oedema, 96 
recognition of, 93 
sudden, of thorax, 95 
(Esophagus, abscess of, 464 
acute inflammation of, 464 
affections of, 461 

dysphagia in, 463 

functional, 465 

subcutaneous emphysema in, 462 
carcinoma of, 464 
chronic inflammation of, 464 
dilatation of, 465 



(Esophagus, foreign bodies in, 465 

hemorrhage from, 462 

normal constriction of, 462 

paralysis of, 466 

physical examination of, 462 

stricture of, 464 
Oligemia, 172 
Oligocythemia, 688 
Ophthalmoplegia, 813 
Osteitis deformans, 66 
Osteomalacia, 68 
Osteomyelitis, 140 
Ovary, cysts of, fluid of, 169 

tumors of, 477 
Ozena, 197 

in glanders, 774 



PACHYMENINGITIS, cerebral, 833 
cervical hypertrophic, 821 
spinal, distinguished from myelitis, 826 
Pain, abdominal, character of, 469 

due to disease of abdominal walls, 
469 

vertebral disease, 469 
in uraemia, 667 
and tenderness in stomach, 485 
character of, 40 

in inflammation of various tissues, 
179 

chest, in tuberculosis, 323 
chronic, in back, 48 
clinical value of, 38 
crises of, 43 
definition of, 35 
duration of, 39 
epigastric, 386 

causes of, 501 
estimation of degree of, 38 
facial expression in, 35 
gastric, 527 (see Gastralgia). 
in abscess of liver, 609 
in affections of intestines, 525 
in aortic aneurism, 423 
in appendicitis, 568 

confounded with intestinal colic, 
527 

in carcinoma, 182 
in cardiac region, causes of, 385 
in diaphragmatic pleurisy, 333 
in diseases of kidneys, 629 

of lungs and pleura?, 293 

of mouth, 430 
in ear, in tonsillitis, 456 
in enlargement of liver, 601 
in extremities, 44 

forerunner of apoplexy, 45 
in gastric affections, 45, 502 

ulcer, 485 
in girdle sensation, 46 
in head, 854 
in hepatic disease, 590 
in herpes, 85 
in joint affections, 141 
in local peritonitis, 527 



874 



INDEX. 



Pain in loins, 47 

in Morton's painful affection of the 
foot, 45 

in neuritis of spinal nerves, 818 

in oesophageal affections, 461 

in pharyngeal affections, 454 

in pleurisy, 333 

in rectal ulcer, 42 

in side, 47 

in spine, 46 

in toxaemias, 41 

in vertebral disease, 46 

location of, 41 

methods of recognizing objectively, 35 
modes of onset of, 39 
modified by pressure, movement, rest, 
43 

pancreatic, 527 

pathology of, 35 

peripheral, of central origin, 42 

posture in, 36 

radiating, 42 

rectal, 527 

reflex actions due to, 36 

in gastric disease, 45 

in liver disease, 45 

in thorax, 45 
sensation of, 788 
simulated, 37 

sources of error in estimating, 36 

sympathetic or reflex, definition of, 35 

time of occurrence, 40 

variations of, in disease, 35 
Palpation, general section on, 52 
Palsies, local, in uraemia, 667 
Pancreas, affections of, pain in, 502 

cyst of, 170, 625 

diseases of, 622 

hemorrhage into, 623 

tumors of, 478, 623 
Pancreatitis, acute hemorrhagic, 624 

gangrenous, 625 

hemorrhagic, distinguished from in- 
testinal obstruction, 566 
suppurative, 624 
Paresthesia, 34 

Paralbumin in ovarian fluid, 169 
tests for, 170 

Paralysis, 790 

acute ascending, 827 
agitans, 846 

distinguished from multiple scle- 
rosis, 844 
gait in, 60 
alternating, 801 
Bell's, 813 

bulbar, larynx in, 220 
diver's, 827 

general, of insane, distinguished from 

multiple sclerosis, 843 
glosso-labial, face in, 119 
-laryngeal, 844 
hysterical, 851 
of fifth nerve, 812 
peripheral facial, face in, 119 



Paralysis, pseudo-hypertrophic muscular 
831 

gait and station in, 61 
vasomotor, 793 
Paramyoclonus multiplex, 137 
Paraplegia, ataxic, 830 

hysterical, distinguished from myelitis, 
826 
gait in, 60 
primary spastic, 829 
spastic, cross-legged progression in, 61 
gait in, 60 
Parasites, 147 
Parotitis, 461 
Pectoriloquy, 263 
Peliosis rheumatica, 722 
Peptonuria in empyema, 331 
Percussion (see Chest). 

general section on, 53 
Pericarditis, acute fibrinous, 393 
causes of, 392 
friction in, 348 
mediastinal, 399 
with effusion, 394 

diagnosis of, Bamberger's sign in, 
397 

physical signs of, 395 
pressure symptoms in, 394 
Pericardium, adherent, 398 

Friedreich's sign in, 398 
pulsus paradoxus in, 398 
air in, 398 
blood in, 398 
diseases of, pain in, 386 
friction sound of, 361 

distinguished from pleural 
friction, 362 
from pleuro-pericardial 
friction, 362 
points for puncture of, 160 
serum in, 397 
Perinephritis, 632 

Peristalsis, unrest of, in gastric neuroses, 
519 

Peritoneum, cancer of, 580 

tuberculosis of, 580 
Peritonitis, 574 

abdominal walls in, 475 
acute tuberculous, confounded with 
appendicitis, 571 
tuberculous, swelling in pubic 
region in, 478 
chronic, 578 

conditions with which confounded, 577 
confounded with intestinal colic, 528 
diagnosis of, 576 

distinguished from intestinal obstruc- 
tion, 565 
friction sound in, 475 
hysterical, 577 
local circumscribed, 577 

pain in, 527 
symptoms of, 575 
vomiting in, 500 
Perspiration, diminished, 77 



INDEX. 



875 



Perspiration, excessive, conditions in which 
it may occur, 76 

local, 76 

prolonged, 76 
Pertussis, 750 
Petri's plates, 156 
Pharyngitis, acute, 459 

chronic, 460 

granular, 460 

phlegmonous, 459 

rheumatic, 460 

spasm of pharynx in, 454 
Pharynx, affections of, cervical glands in, 
453 

subjective symptoms of, 454 
anaesthesia of, 453 
and fauces, diseases of, 449 
eruption of measles in, 450 
eruptions in, 451 
exudations on, 453 
hyperesthesia of, 453 
paralysis of, 450 
spasm of, 454 

ulceration of, cancerous, 453 
follicular, 452 
syphilitic, 452 
tuberculous, 453 
Phosphates, triple, in pus, 167 
Phthisis (see Tuberculosis). 

confounded with aortic aneurism, 423, 
428 

Plague, the, 777 
Plethora, 172 

Pleura, air in, distinguished from emphy- 
sema, 267 
aspiration of, 160 
effusions into, decubitus in, 58 
pulsating effusion of, 332 
thickened, 332 
Pleurae, affections of, 222 

air in lungs in, 224 
effusion into, confounded with enlarged 
liver, 599 
distinguished from pulmonary 

consolidation, 267 
movement of chest in, 240 
friction sound of, 261 
Pleurisy, acute, 329 
aegophony in, 330 
bronchial breathing in, 257, 330 
causes of, 329 
chronic, 334 
diagnosis of, 333, 334 
diaphragmatic, 333 
displacement of organs in, 330 
effusion in, physical signs of, 330 
exploratory puncture in, 333 
pain in, 293 

conditions with which confounded, 
294 

purulent (see Empyema), 
rheumatic, 707 
Skoda' s resonance in, 330 
tuberculous, 332 
Pleurodynia, 385, 710 



Pleurodynia, distinguished from pleurisv, 

240, 334 
Pleximeter, Sansom's, 351 

data obtained by, 352 
repercussion with, 352 
Pneumococcus (see Micrococcus lanceo- 
latus). 

Pneumonia, broncho-, distinguished from 
collapse of the lung, 327 
catarrhal, 313 

diagnosis of, 314 

physical signs of, 313 

tuberculous form of, 314 
chronic interstitial, 314 
croupous or lobar, 308 

bacteriological diagnosis in, 313 

bilious, 312 

central, 308 

cerebral symptoms in, 310 
complications in, 313 
cutaneous symptoms in, 310 
diagnosis of, 312 

distinguished from collapse of the 

lung, 327 
duration and course of, 311 
fever in, 310 

gastro-intestinal symptoms in, 310 
heart and pulse in, 310 
in wasting diseases, 312 
micrococcus lanceolatus in (see 

Sputum), 
migratory, 312 
mode of onset of, 308 
physical signs of, 311 
pseudo-crisis in, 310 
pulse-respiration ratio in, 309 
respiratory symptoms in, 308 
rusty sputum of, 309 
typhoid, 312 
urine in, 311 

distinguished from influenza, 752 
from pleurisy, 334 

facies in, 118 

movement of chest in, 240 
sputum in, 269 

without bronchial breathing, 257 
Pneumonokoniosis, 314, 315 
Pneumoptosi in gastric neuroses, 518 
Pneumothorax, 335 

diagnosis of, 336 

movement of chest in, 240 

signs of, 336 
Poikilocytosis, 688 
Poliomyelitis, anterior, 826 

chronic, 831 
Pons, lesions of, 801 
Posture in diagnosis, 57 

in pain, 36 
Pregnancy, extra-uterine, cause of pelvic 
hematocele, 477 
confounded with uterine colic, 527 
Pressure, sense of, 788 
Proctitis, 550 
Pruritus in uraemia, 667 
Ptomaines, 149 



876 



INDEX. 



Ptosis, 811 

morning, 811 
Ptyalism, mercurial, 437 
Puerperium, pulse in, 375 
Pulmonary insufficiency, 414 

osteo-arthropathy, 66 

stenosis, 414 
Pulsation, epigatric, 368, 484 

of organs, 370 
Pulse affected by condition of arterial 
walls, 372 

capillary, in aortic incompetency, 406 

Corrigan's or water-hammer, 867 

frequency of, 370 

diagnostic significance of, 374 

in aortic aneurism, 426 

in dilatation of heart, 418 

in hypertrophy of left ventricle, 416 

intermittent, 373 

irregular, 374 

method of taking, 371 

rate of, in fever, 106 

rhythm of, 373 

sphygmographic tracings of, interpre- 
tation of, 378 
tension of, high, causes of, 372 

in true and false angina pectoris. 

373 
low, 373 
venous, 383 
volume of, 373 
Pupil, Argyll-Robertson, 811, 829 
Purpura, 721 
Pus, 161 

abnormal, 167 

amoeba dysenterica in, 162, 166 

chemical examination of, 167 

crystals in, 167 

protozoa in, 166 

sero-, 167 

vermes in, 167 
Pyelitis, 680 
Pyonephrosis, 631, 680 
Pyo-pneumothorax subphrenicus, 337, 
479 

Pyrosis in gastric affections, 503, 518 



QUINSY, 456 



RALES, crepitant, in influenza, 752 
kinds of, 259 
recognition of, 260 
Eanula, 440, 443 
Rashes caused by drugs, 86 
[Raynaud's disease, 131 
Recording cases (see Case records). 
Rectum, diseases of, 574 
Reflexes, cutaneous, 792 
delay in, 792 
patellar, 793 

in diphtheria, 756, 758 
tendon, 793 



Resonance, vocal, 262 

Skoda's, 330 
Respiration, Cheyne-Stokes, 239 
cause of, 285 

in fever, 106 
Retinitis, 806 

albuminuric, 806 
Rhachitis, 67, 715 

face in, 119 

laryngismus in, 213 

perspiration of head in, 77 
Rheumatic diathesis, relation of stomach 
to, 522 # 

Rheumatism, abdominal, confounded with 
intestinal colic, 528 
acute articular, 705 
complications and sequela? of, 707 
diagnosis of, 708 
duration of, 708 

endocarditis and pericarditis in, 
707 

subcutaneous nodosities in, 708 
affections of tonsils in, 450 
chronic articular, 709 
gonorrhoeal, joint of, 141 
joint of, 142 
muscular, 710 
nodules in, 99 

of abdominal walls, confounded with 
peritonitis, 577 
pain in, 469 
relation to lithsemia, 586 
subacute articular, 709 
Rheumatoid arthritis (also see Arthritis), 
freckles in, 75 
Gubler's tumor in, 129 
joint of, 142 
outline of joints in, 140 
Rhinitis (see also Nose), 
atrophic, 197 
caseous, 193 

chronic hypertrophic, 196 

diphtheritic, 195 

secretions in, 193 

sicca, 197 

simple acute, 194 
Rhinoliths, 198 
Rhinoscopy, 191 
Rhinorrhoea, idiopathic, 200 

strumous, 197 
Rhonchi, 243, 259 
Rhythmical contractions, 791 
Ribs, periostitis of, in precordial region, 
385 

Roseola, differential diagnosis from acute 

infectious diseases, 87 
Rubella, 749 

distinguished from scarlatina, 748 

SALIVA, chemical examination of, 432 
fungus of thrush in, 433 
in disease, 433 
micro-organisms in, 432 
microscopical examination of, 431 



INDEX. 



877 



Saliva, sugar in, test for, 433 

sulpho-cyanide of potassium in, 433 
Salivation, 437 

Salpingitis confounded with typhoid fever, 
733 

Saprsemia, 147 
Saprophytes, 147 
Sarcinse, 148 

Scalp, affections of, pain in, 854 
Scarlatina, 744 

anginosa, 747 
Scars, significance in diagnosis, 77 
Schizomycetes, 147 
Sciatica, 819 

in tumor of kidney, 678 
Scleroderma, 98 

Sclerosis, disseminated insular, gait in, 60 

lateral, 827 

multiple, 843 

speech in, 220 

posterior, larynx in, 220 
Scurvy, 716 

brawny induration in, 98 

gums in, 434 

hemorrhage in, 79 
Seitz's sign of cavity, 264 
Sensation, delayed conduction of, 788 
Sense, muscular, 788 
Sensibility, disturbances of, 787 

tactile, 787 
Sex in aetiology of disease, 25 
Shock, 117 

causes of, 177 
Sinus, frontal, inflammation of, 189, 199 

sphenoidal and ethmoidal, inflamma- 
tion of, 199 
Skin, bronzed, 73 

conditions with which confounded, 
74 

color of, 68 

in various diseases, 70 

deep affections of, 91 

eruptions of, in internal diseases, 79 
anatomical characters of, 80 
associated morbid phenomena in, 
81 

clinical significance of, 80 
distribution of, 81 
general health in, 82 
itching in, 82 

table of, with diseases in which 
they may occur, 83 
glossy, 132 
hemorrhage into, 77 
cause of, 78 
in fever, 78 
significance of, 78 
Vierordt's test for, 78 
inflammations of, superficial, 91 
moisture and dryness of, 75 
nutrition of, 75 
scars of, 77 
Skoda' s resonance, 330 
" Sleeping sickness," 704 
Smell, sense of, disturbance of, 189 



Solutions, Gabbett's, 279 
Gibbes', 279 
Koch-Ehrlich, 278 
of aniline dyes, 153 
Ziehl-Neelsen, 278 
Spansemia, 172 
Spasms, 791 

coordinated, 792 
tonic, 792 
vasomotor, 793 
Speech, centres of, 797 
Spermatorrhoea, 657 
Sphygmograph, 375 

Dudgeon's, directions for using, 376 
technique of, 377 
Spinal column, curvature of, 139 
cord, anaemia of, 823 

anterior horns of, 804 
antero-lateral columns of, 804 
compression of, 823 
degenerations of, 828 
hemorrhage into, 822, 827 
hypersemia of, 823 
localization of, 803 
posterior columns of, 804 
tumors of, 833 
unilateral lesions of, 804 
Spine, pain in, 46 
Spirilla, 150 

of Finkler and Prior, 150 
Spirillum cholera? Asiaticse, 545 
cholera nostras, 546 
Obermeieri, 737 
Spirometry, 265 

Spleen, acute enlargement of, 620 

distinguished from enlarged 
kidney, 620 
amyloid, 621 

chronic enlargement of, 621 

enlargement of, in young children, 622 

exploratory puncture of, 160 

floating, 619, 620 

hydatid tumor of. 622 

in chronic malaria, 621 

in cirrhosis of liver, 605 

in dilatation of stomach, 513 

malignant tumors of, 622 

palpation of, 619 

percussion of, 620 

syphilis of, 622 
Splenitis, acute, 620 
Spores of bacilli, 149 

staining of, 154 
Sputum, actinomyces in, 281 

alveolar epithelium in, 270 

bacillus of influenza in, 281 

chemistry of, 281 

collection of, for examination, 152 

crystals in, 274 

elastic fibres in, 271 

examination of, 268 

fibrinous coagula in, 272 

in amoebic hepato pulmonary abscess, 
556 

in oesophageal affections, 461 



878 



INDEX. 



Sputum in bronchiectasis, 300 

laryngeal, 207 

method of collecting, 267 

micrococcus lanceolatus in, 280 

parasites in, 275 

spirals in, 272 

tubercle bacillus in, 276 

detection of, if few in num- 
ber, 279 
importance of, 279 
methods of staining, 277 

varieties of, 268 
Staining, of blood in leucocythsemia, 695 

methods of, 153 
Staphylococci, 148 

pyogenic, 162 
Station (see Gait). 
Sterilization in bacteriology, 151 

intermittent, 151 
Stethoscopes, 252 

Stomach, absorptive energy of, test for, 493 
actual diminution in size of, 486 
artificial distention of, by gas or air, 

486 
atony of, 519 

and atrophy of, 507 
auscultation of, 487 
bougie, its use and contra-indications 

in examination of, 484 
cancer of, 484, 507 
diagnosis of, 509 

examination of gastric contents 

in, 509 
pain in, 502 

tabulated diagnosis from gastric 
ulcer and chronic gastritis, 510 

vomiting in, 499 
contents of, alcohol in, 493 

and activity of digestion in dis- 
ease of, 482 

as index of digestive energy, 490 

bile and intestinal juice in, 489 

blood in, 489 

carbohydrates in, test for, 493 
fatty acids in, 492 
HC1 in, quantitative estimation of, 
491 ■ 

significance of, 492 

tests for, 490 
inspection of, 489 
lactic acid in, 492 
methods of securing, for examina- 
tion, 487 
microscopical examination of, 494 
mucus in, 489 
pepsin in, test for, 493 
peptones in, test for, 493 
pus in, 490 

rennet in, test for, 493 

test breakfast in examining, 490 

total acidity of, 492 

digestive energy of, Gunsburg's test 
for, 493 

dilatation of, 486, 512 

diseases of, 480 



Stomach, diseases of, alterations of appe- 
tite in, 503 
central and reflex influences in, 481 
constipation or diarrhoea in, 504 
flatulency in, 501 
functional symptoms of, 481 
hiccough in, 504 

morbid processes in other organs 
causing symptoms of, 483 

organs functionally related, 483 

pain in, 45, 46, 501 

pyrosis or water-brash in, 503 

regurgitation of gas or food in, 
503 _ 

subjective symptoms in, 496 

symptomatology of, 480 

toxic symptoms in, 483 

vertigo in, 501 

vomiting in, 495 
hemorrhage from, 495 
causes of, 495 
hyperacidity and hypersecretion of, in 

gastric neuroses, 517 
local diseases of, vomiting in, 498 
method of passing tube into, 488 
motor power of, test for, 494 
neuroses of, 513 (also see Dyspepsia). 

diagnosis of, 520 

Ewald's table of, 513 
non-malignant tumors of, 484 
normal contents of, characters of, 488 
pain and tenderness in, 485 
palpation of, 484 
percussion area of, 486 
peristaltic and anti-peristaltic waves 
of, 483 

physical examination of, 483 

position of, 485 

rupture of, 513 

succussion splash of, 487 

symptoms of affections of, in other 

diseases, 521 
tympany of, distinguished from that of 

colon, 486 
ulcer of, 510 

pain in, 502 

tabulated diagnosis from gastric 
cancer and chronic gastritis, 510 
vomiting in, 499 
Stomatitis, aphthous, 436 

catarrhal, 436 

gangrenous, 437 

materna, 437. 

mercurial, 437 

parasitic, 437 

ulcerative, 436 
Streptococci, 148 

pyogenic, 163 
Succussion, Hippocratic, 262, 336 
Sudamina, 8S 
Suppuration, fever of, 178 

indican in urine in, 331 

loss of appetite attending, 503 

peptonuria in, 331 
Suppurations, contagious, 723 



INDEX, 



879 



Sweating sickness, 76, 779 
Sweats in tuberculosis, 323 
Symptoms, cerebral, in fever, 107 

of disease, objective, definition of, 17 
in general diagnosis, 49 
subjective, definition of, 17 
general, 33 
nature of, 33 
value of, 31 
Syphilis, brawny induration in, 98 
caries of frontal bone in, 121 
congenital, eruptions in, 90 

teeth of, 435 
constitutional, 780 
eruptions of, 89 
hereditary, 782 
neuralgia in, 856 
tenderness of sternum in, 139 
tertiary ulcers of, 90 
ulcers of pharynx in, 452 
Syringomyelia, 833 



TABES dorsalis (see Locomotor ataxia), 
mesenterica, 480 
Tachycardia, 374 
Tsenise, 541 

symptoms of, 524 
Teeth, carious, cause of headache or neu- 
ralgia, 435 
dates of eruption of, 436 
effect of stomatitis on, 435 
in hereditary syphilis, 782 
of congenital syphilis, 435 
Teething, 435 

Temperament, section on, 55 
Temperature (also see Fever). 

collapse, 102 

determination of, 100 

febrile, 102 

hectic, 76 

hyperpyretic, 102 

in ursemia, 675 

in uremic convulsions, 667 

inverted, 105 

recrudescent, 105 

sense of, 788 

subnormal, 109, 112 

sudden fall in, 112 
rises in, 111 

variations of, pathological, 102 
physiological, 101 
Tetanus, 847 

bacillus of, 166 
Tetany, 847 
Thalamus, optic, 800 
Thermometer, 100 
Thirst as a symptom, 496 
Thorax (see Chest). 

reflex pains in, 45 
Thrombosis, 173 

causes of, 174 

cerebral, 841 

in arterial sclerosis, 420 

inflammatory or septic, 174 



Thrombosis, of superior longitudinal sinus 7 
840 

Thrush, 433, 437 
Thyroid, enlargements of, 126 
Tic douloureux, 789, 812 
Tinea versicolor confounded with Addi- 
son's disease, 74 
Tongue, atrophy of, 443 

black, 439 

chancre of, 442 

coating on, 444 

cyanosis of, 445 

cysts of, 443 

dry brown, 445 

effects of food on, 447 

eruptions on, 440 

examination of, 438 

furred or shaggy, 445 

furrows of, 440 

hypertrophy of, 443 

indentations and excoriations of, 440 

inflammation of (see Glossitis). 

in angina Ludovici, 449 

in relation to diseases of the alimen- 
tary canal, 447 

in treatment and prognosis, 448 

in various diseases, 448 

moisture of, 447 

movements of, 448 

mucous patches on, 443 

patches and plaques on, 442 

plaster, 445 

red dry, 445 

sclerosis of, 441 

stippled or dotted, 444 

strawberry, 444, 746 

syphilitic fissures of, 441 

tuberculous ulcer of, 442 

ulcers of, 441 

wandering rash on, 443 

xanthelasma of, 439 
Tongues, classification of, 446 
Tonsillitis, catarrhal or erythematous, 454 

chronic, 457 

diagnosis of, 456 

follicular, 455 

distinguished from diphtheria, 

456, 757 
odor of breath in, 454 

herpetic, 455, 456 

suppurative, 456 
Tonsils, 451 

affections of, in rheumatic states. 
450 > 

exudations on, 453 

foreign bodies in, 457 

leptothrix of, 453 
Torticollis, 710, 817 
Toxaemia, 147 
Toxalbumins, 149 

Tracheal tugging, detection of, 126, 427 
Tract, optic, diseases of, 807 
Transudations, specific gravity in, 168 
Tremor, 791 
Triangle, Simon's, 739 



880 



INDEX. 



Trichina spiralis in faeces, 543 
Trichinosis, 779 
face in, 120 
oedema in, 95 
Tricuspid incompetency, 412 
venous pulse in, 384 
stenosis, 413 
Trophic disturbance, 793 
Tubercle bacillus in pus, 163 
Tuberculosis, 783 

acute miliary, 317, 784 

pulmonary, distinguished from 
typhoid fever, 733 
chronic, 318 

diagnosis of, 325 
diagnostic features of, 321 
early signs and seats of, 319 
infection in, 324 
modes of invasion of, 318 
physical signs of, 321, 324 
progress of, 320 
sputum in, 324 

vomiting in early stages of, 324 
dyspeptic symptoms in, 521 
haemoptysis in, 291 
intermittent type of fever in, 113 
of kidney, 677 
of larynx, 216 
of mesenteric glands, 480 
of occipito-atlantal articulation, 121 
pulmonary, acute, 315 

definition of, 315 

distinguished from pneumonia, 
317 

expectoration in, 317 
physical signs of, 316 
pneumothorax in, 335 
Tubes, Esmarch's, 156 
Tumors, of abdomen, 472 

phantom, 472 
Tympanites hysterical, 852 
Typhlitis, 571 

tumor of, 476 
Typhoid fever (see Fever), 
state described, 107 

in nervous affections, 107 



ULCER, duodenal, 557 
gastric, pain and tenderness in, 485 
Uraemia, cerebral symptoms of, 666 

chronic, confounded with typhoid, 
734 

distinguished from apoplexy, 839 
dyspnoea in, 667 

gastro-intestinal, symptoms of, 667 
in chronic productive nephritis, 673, 
675 

vomiting in, 500 
Urine, acetone in, 648 
albumin in, 639 

boiling test for, 639 
necessity of clear solution in test- 
ing for, 641 



Urine, albumin in, nitric acid test for. 
640 

picric acid test for, 640 
quantitative estimation of, 641 
albumose in, 644 

bile pigments and bile acids in, 647 
blood in, 643, 649 
calcium oxalate in, 664 
casts in, method of examining for, 
652 

varieties of, 655 
chlorides in, 639 
cholesterin in, 665 
color of, normal and abnormal, 633 
cylindroids in, 656 
cystin in, 665 
density of, 636 
diacetic acid in, 648 
diazo-reaction of, in typhoid, 727 
entozoa in, 660 
epithelium in, 659 

extraneous matters in sediments of, 

649 
fat in, 659 
haemoglobin in, 644 
indican in, 647 

in acute exudative nephritis, 671 

productive nephritis, 672 
in amyloid disease of kidney, 678 
in chronic productive nephritis, 673, 
674 

in lithaemia, 586 

in organic heart disease, 391 

in pyelitis, 680 

in tumors of kidney, 661 

leucin and tyrosin in, 665 

melanin in, 666 

microscopic examination of, 648 

micro-organisms in, 660 

mucin in, 643 

odor of, 637 

peptone in, 643 

phosphates in, 663 

preservation of specimens of, 650 

pus in, 648, 651 

reaction of, 636 

sediments in, 637 

centrifugal machine for securing, 
649 

solids in, specific gravity as index of, 
636 

spermatozoa in, 657 
sugar in, 644 

Fehling's test for, 644 
fermentation test for, 645 
phenyl-hydrazin test for, 645 
quantitative estimation of, 645 
suppression of, causes of, 635 
urates in, 663 
urea in, 638 
uric acid in, 662 

murexid test for, 637 
volume of, in disease, 635 
Urticaria, 86 
Uvula, affections of, 452 



INDEX. 



881 



VALVE, ileo-csecal, stricture of, 477 
Varicella, 741 

distinguished from varioloid, 741 
Variola, 738, 740 
Varioloid, 740 
Vasomotor apparatus, 186 
Vein, portal, suppurative inflammation of, 
588 

symptoms of obstruction of, 588 
Veins, hum heard over, 384 

increase in size of, causes of, 382 

pulsation of, 383 

in tricuspid insufficiency, 413 

pulse of, 383 

rhythm of, 383 

thrombosis of, 384 
Vermes, round, 542 

taeniae, 541 

trematodes or flukes, 542 
Vertigo, aural, 815 

in gastric affections, 501 

paralyzing, 815 
Volvulus, 559 
Vomiting, 496 

determination of, cause of, 498 

in Addison's disease, 699 

in chronic gastritis, 506 



Vomiting in intestinal obstruction, 561 

in local affections of stomach, 498 

in onset of acute diseases, 499 

in toxaemias, 500 

nervous, in gastric neuroses, 519 

physiology of, 497 

reflex, 499 

uraemic, 667 
Von Graefe's sign, 701 

WASTING in aortic aneurism, 423 
Weight in relation to height, 63 
Hutchinson's table of, 64 
Weil's disease, 595 
Whooping-cough, 750 

sublingual ulcer in, 438 
Wintrich's signs of cavity, 264, 336 
Worms, intestinal, symptoms of, 524 
Wrist-drop, 128 

^ANTHELASMA, 123 
yOOGL(EM, 148 



LEA BROTHERS & CO S 



CLASSIFIED CATALOGUE 

OF 




Medical m Surgical ;l 

Publications. 

- — |*t 

N ASKING the attention of the profession to the works advertised in the follow- • Q 

ing pages, the publishers would state tlial no pains are spared to secure a q> *q 

continuance of the confidence earned for the publications of the house $3 

by their careful selection and accuracy and finish of execution. & ^ 

The printed prices are those at which books can generally be supplied by booksellers . ^ 

throughout the United States, who can readily procure for their customers any works not ^>H-> 

kept in stock. Where access to bookstores is not convenient books will be sent by mail by *^ ^ ^ 

the publishers postpaid on receipt of the printed price, and as the limit of mailable weight Q> ^ q 

has been removed, no difficulty will be experienced in obtaining through the post-office Q£ tj3 

any work in this catalogue. No risks however are assumed either on the money or ^ • ^ 

on the books, and no publications but our own are supplied, so that gentlemen will in {/) ^ pq 
most cases find it more convenient to deal with the nearest bookseller. 

LEA BKOTHERS & CO. ^ 5 

Nos. 706, 708 & 710 Sansom St., Philadelphia, February, 1894. ^ UJ ^ 

.2 ^ 4 

Practical Medical Periodicals. £ 



THE AMERICAN JOURNAL OF THE MEDICAL n To one address, 

post-paid, 

SCIENCES, Monthly, $4.00 per annum. I £ '~ _ 

THE MEDICAL NEWS, Weekly, $4.00 per annum. ) per annum. 

THE flEDICAL NEWS VISITING LIST (4 styles, see page 3), $1.25. 
With either or both above periodicals, in advance, 75c. 

THE YEAR=BOOK OF TREATMENT (see page 16), $1.50. With either 
JOURNAL or NEWS, or both, 75c. Or JOURNAL, NEWS, VIS- 
ITING LIST AND YEAR=BOOK, in all $10.75, for $8 50 in advance. 



Subscription Price Reduced to $4.00 Per Annum. 

THE MEDICAL NEWS. 

KEEPING closely in touch with the needs of the active practitioner, The 
News has achieved a reputation for utility so extensive as to render practicable 
its reduction in price from five to Four Dollars per annum. It is now by 
far the cheapest as well as the best large weekly medical journal published 
in America. Employing all the recognized resources of modern journalism, such as the 
cable, telegraph, resident correspondents, special reporters, etc., The News supplies 
in the 28 quarto pages of each issue the latest and best information on subjects of 
importance and value to practitioners in all branches of medicine. The foremost writers, 
teachers and practitioners of the day furnish original articles, clinical lectures and notes 

(Continued on next page.) 



2 Medical Periodicals, Visiting List, Ledger. 



THE nEDICAL NEWS===Continued. 

on practical advances ; the latest methods in leading hospitals are constantly reported ; 
a condensed summary of progress is gleaned each week from a large exchange list, com- 
prising the best journals at home and abroad ; a special department is assigned to abstracts 
requiring full treatment for proper presentation ; editorial articles are secured from 
writers able to deal instructively with questions of the day ; books are carefully 
reviewed ; society proceedings are represented by the pith alone ; regular correspondence 
is furnished from important medical centres, and minor matters of interest are grouped 
each week under news items. In a word The Medical News is a crisp, fresh, weekly 
professional newspaper and as such occupies a well-marked sphere of usefulness, distinct 
from and complementary to the ideal monthly magazine, The American JohrnaIj 
of the Medical Sciences. 

The American Journal | PublishedMonthly 

of the | at $4.00 

Medical Sciences i 



Per Annum. 



The American Journal enters with 1894 upon its seventy-fifth year, still main- 
taining the foremost place among the medical magazines of the world. A vigorous 
existence during two and a half generations of men amply proves that it has always 
adapted itself to meet fully the requirements of the time. 

Being the medium chosen by the best minds of the profession during this 
period for the presentation of their ablest papers, The American Journal has well 
earned the praise accorded it by an unquestioned authority — "From this file alone, were all 
other publications of the press for the last fifty years destroyed, it would be possible to reproduce 
the great majority of the real contributions of the world to medical science during that period." 
Original Articles, .Reviews and Progress of the Medical Sciences constitute the three main 
departments of this ideal medical monthly. 



COMMUTATION RATE. 

Taken together, The Journal and The News afford to medical readers the ad- 
vantages of the monthly magazine and the weekly newspaper. Thus all the benefits of 
medical periodical literature can be secured at the low figure of $7.50 per annum. 



Subscribers can obtain, at the close of each volume, cloth covers for The Journal (one 
annually), and for The News {one annually), free by mail, by remitting Ten Cents for The 
Journal cover, and Fifteen Cents for The News cover. 



The Medical News Visiting List for 1894 

Is published in four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 120 
patients per month) ; Perpetual (undated, for 30 patients weekly per year) ; and Per- 
petual (undated, for 60 patients weekly per year). The 60-patient Perpetual consists 
of 256 pages of assorted blanks. The first three styles contain 32 pages of important 
data and 176 pages of assorted blanks. Each style is in one wallet-shaped book, leather- 
bound, with pocket, pencil, rubber, and catheter- scale. Price, each, $1.25. 



This list is all that could be desired. It eon- 
tains a vast amount of useful information, especi- 
ally for emergencies, and gives good tables of doses 
and therapeutics. — Canadian Practitioner. 

Its compactness and simplicity are such as to 
indicate that the highest point of perfection has 
been reached in works of this class. — University 
Medical Magazine. 



The new issue maintains its previous reputation. 
It adapts itself to every style of book-keeping; 
there is space for all kinds of professional records ; 
it is furnished with a ready reference thumb-letter 
index, and has a most valuable text.— Medical 
Record. 

For convenience and elegance it is not surpass- 
&b]e.— Obstetric Gazette. . 



SPECIAL COMBINATIONS WITH THE VISITING LIST, see p. 1. 

J^^The safest mode of remittance is by bank check or postal money order, drawn to 
the order of the undersigned ; where these are not accessible, remittances for subscriptions 
may be sent at the risk of the publishers by forwarding in registered letters addressed to 
the Publishers (see below j. 

The Medical News Physicians' Ledger. 

Containing 300 pages of fine linen " ledger " paper, ruled so that all the accounts of a 
large practice may be conveniently kept in it, either by single or double entry, for a long 
period. Strongly bound in leather, with cloth sides, and with a patent flexible back, 
which permits it to lie perfectly flat when opened at any place. Price, $4.00. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia, 



Medical Dictionary, Quiz Manuals. 



3 



THE STUDENTS' 

DICTIONARY OF MEDIGINE 

AND THE ALLIED SCIENCES, 

comprising the pronunciation, derivation and full explanation of medical 
terms; together with much collateral descriptive matter, 
numerous tables, etc. 
By ALEXANDER DUANE, M. D., 

Assistant Surgeon to the New York Ophthalmic and Aural Institute; Reviser of Medical Terms for 
Webster'a International Dictionary. 

In one square octavo volume of 658 pages. Cloth, $4.25 ; half leather, $4.50 ; full 
sheep, $5.00. Just ready. 



It is eminently a work for the medical student. 
A special feature of this work is the omission of 
obsolete terms, thus making room for fuller defi- 
nitions of those in use. This, with the tabulation 
of many subjects and the use of cross-references, 
not only accomplishes the purpose, but facili- 
tates reference— a most desirable quality in any 
dictionary. Another feature in the phonetic sys- 
tem of pronunciation instead of the more or less 
elaborate system of diacritical marks generally 
used by lexicographers. Inspection shows that 
the correct pronunciation is easily conveyed . The 
definitions are unusually clear and concise, and 
in many cases almost encyclopedic— The Pitts- 
burg Medical Review, December, 1893. 

The best medical dictionary for its size that is 
anywhere published. Utility with accuracy of 
information have been the guiding designs. — Va. 
Med. Monthly, Jan. 1894. 

The work is the best student's dictionary we 
have seen. It is strong on pronunciation and 
derivation, two very important points. — The Canada 
Lancet, January, 1894. 



Dr. Duane is known as the Reviser of Medi- 
cal Terms for Webster's International Dictionary. 
The special training he received in that work has 
served as the best of preparations for a volume of 
this character. Medical students are here pro- 
vided with full information concerning every 
word they will meet in acquiring their profes- 
sional education. Each word is followed by its 
correct pronunciation, shown by means of simple 
phonetic spelling. The definitions of the words 
are of an explanatory style, giving much descrip- 
tive matter as well as a statement of meaning. 
We thus have a volume that must receive attention 
for its practical utility. The size of the book is 
such that it can be used without disadvantage, 
while the price brings it within the reach of the 
largest number of those needing it. There can be 
no doubt that it will have a most extensive sale 
amoiit, all students of medicine, and that its 
clear and sufficient definitions will make it a good 
working volume for the practitioner. — The Na- 
tional Medical Review, December, 1893. 



THE STUDENTS' QUIZ SERIES. 

ANEW Series of Manuals, comprising all departments of medical science and practice, 
and prepared to meet the needs of students and practitioners. Written by promi- 
nent medical teachers and specialists in New York, these volumes may be trusted as 
authoritative and abreast of the day. Cast in the form of suggestive questions, and concise 
and clear answers, the text will impress vividly upon the reader's memory the salient 
points of his subject. To the student these volumes will be of the utmost service in pre- 
paring for examinations, and they will also be of great use to the practitioner in recalling 
forgotten details, and in gaining the latest knowledge, whether in theory or in the actual 
treatment of disease. Illustrations have been inserted wherever advisable. Bound in 
limp cloth, and in size suitable for the hand and pocket, these volumes are assured of 
enormous popularity, and are accordingly placed at an exceedingly low price in com- 
parison with their value. For details of subjects and prices see below. 



ANATOMY {Double Number) — By Fred J. 
Brockway, M. D., Assistant Demonstrator of 
Anatomy, College of Physicians and Surgeons, 
New York, and A. O'Malley, M.D., Instructor 
in Surgery, New York Polyclinic. $1.75. 

PHYSIOLOC Y — By F. A. Manning, M. D., 
Attending Surgeon, Manhattan Hosp., N.Y. $1. 

CHEMISTRY AND PHYSICS— By Joseph 
Strtjthers, Ph. B., Columbia College School of 
Mines, N.Y., and D. W. Ward, Ph. B., Columbia 
College School of Mines, N. Y., and Chas. H. 
Willmarth, M. S., N. Y. $1. 

HISTOLOGY, PATHOLOGY AND BAC- 
TERIOLOGY— By Bennett S. Beach, M. D., 
Lecturer on Histology, Pathology and Bacte- 
riology, New York Polyclinic. $1. 

MATERIA MEDICA AND THERAPEU- 
TICS— By L. F. Warner, M.D., Attending 
Physician, St. Bartholomew's Disp., N. Y. $1. 

PRACTICE OF MEDICINE, INCLUDING 
NERVOUS DISEASES— By Edwin T.Dou- 
bledat, M.D., Member N.Y. Pathological Soci- 
ety, and J. D. Nagel, M.D., Member N. Y. 
Counly Medical Association. $1. 

SURGERY {Double Number)— By Bern B. Gal- 
laudet, M. D., Visiting Surgeon, Bellevue 
Hospital, N.Y., and Charles Dixon Jones, M. D., 
Assistant Surgeon Out-Patient Department, 
Presbyterian Hospital, N. Y. $1.75. 



GENITO - URINARY AND VENEREAL 
DISEASES— By Charles H. Chetwood, M.D., 
Visiting Surgeon, Demiit Dispensary, Dep. of 
Surg, and Gen.-Urin. Dis., New York. $1. 

DISEASES OF THE SKIN — By Charles C. 
Ransom, M. D., Assistant Dermatologist, Van- 
derbilt Clinic, New York. $1. 

DISEASES OF THE EYE, EAR, THROAT 
AND NOSE— By Frank E. Miller, M.D., 
Throat Surgeon, Vanderbilt Clinic, New York, 
James P. McEvoy, M.D., Throat Surgeon, Belle- 
vue Hosp., Out-Patient Dep., New York, and 
J. E. Weeks, M. D., Leet. on Ophthal. and 
Otol., Bellevue Hosp., Med. Co!., N. Y. $1. 

OBSTETRICS — By Charles W. Hayt, M.D., 
House Physician, Nursery and Child's Hospi- 
tal, New York. 81. 

GYNECOLOGY— By G. W. Bratenahl, M. D., 
Assistant in Gynecology, Vanderbilt Clinic, 
New York, and Sinclair Tot/sey, M. D., Assist- 
ant Surgeon, Out-Patient Department, Roose- 
velt Hospital, New York. $1. 

DISEASES OF C H I L D R E N — By C. A. Rhodes, 
M. D., Instructor in Diseases of Children, New 
York Post-Graduate Medical College. $1. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



4 



Dictionaries. 



NEW (21st) EDITION. THOROUGHLY REVISED. JUST READY. 

Dunglison's Dictionary 

OF MEDICAL SCIENCE. 

With the Pronunciation. Accentuation and Derivation of the Terms. 

Containing a full Explanation of the various Subjects and Terms of Anatomy, Physiology, 
Medical Chemistry, Pharmacology, Pharmacy, Therapeutics, Medicine, Hygiene, Dietet- 
ics, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology, Obstetrics, 
Pediatrics, Medical Jurisprudence and Dentistry, etc., etc. By Pobley DuNGLiS0N r 
M. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Phila- 
delphia. New (21st) edition, thoroughly revised and greatly enlarged. With the Pro- 
nunciation, Accentuation and Derivation of the Terms, by Richard J. Dunglison, 
A.M., M. D. In one very large and handsome royal octavo volume of 1191 pages. 
Cloth, $7.00 ; leather, raised bands, $8.00. 

THIS great medical dictionary, which has been for more than two generations the 
standard of the English speaking race, is now issued in a thoroughly revised and 
greatly enlarged and improved edition. The new words and phrases aggregate 
by actual count over 44,000. Space has been gained by the excision of everything obsolete, 
and the page has been much enlarged, so that though the new edition contains far more matter 
than its predecessor, the whole is accommodated within a volume convenient for the hand. 

The revision has not only covered every word, but it has resulted in a number of 
important new ieatures designed to confer on the work the utmost usefulness, and to make 
it answer the most advanced demands of the times. 

Pronunciation has been introduced throughout by means of a simple and obvious 
system of phonetic spelling. At a glance the proper sound of a word is clearly indicated, 
and thus a most important desideratum is supplied. 

Derivation affords the utmost aid in recollecting the meanings of words, and gives 
the power of analyzing and understanding those which are unfamiliar. It is indicated in 
the simplest manner. Greek words are spelled with English letters, and thus placed at 
the command of those unfamiliar with the Greek alphabet. 

Definitions, the essence of a dictionary, are clear and full, a characteristic in 
which this work has always been preeminent. In this edition much explanatory and 
encyclopedic matter has been added, especially upon subjects of practical importance. Thus 
under the various diseases will be found their symptoms, treatment, etc. ; under drugs their 
doses and effects, etc., etc. Avast amount of information has been clearly and conveniently 
condensed into tables in the alphabet. 

In a word, Dunglison's Medical Dictionary, in its remodelled and enlarged shape, is 
equal to all that the student and practitioner can expect from such a work. 

Their estimate of Dunglison's Dictionary le d the 



The new " Dunglison" is new indeed. The vast 
amount of new matter and the thoroughness with 
which the work has been brought down to date 
cannot fail to strike even the J east observant 
reader. The immense advances made in all 
branches of medical science here find represen- 
tation. A prominent and very useful feature of 
the old book is retained and amplified in this — we 
mean the tables, which recur with great fre- 
quency and represent a vast amount of condensed 
information. In respect to accuracy the book quite 
equals and usually surpasses any of its contempo- 
raries that we are acquainted with. The new 
"Dunglison" has been brought down to date, so 
as to represent adequately the latest advances in 
medical science. — The American Journal of the 
MeMcal Sciences, January, 1894. 

Of all the numerous books published in recent 
years not one can compare with it in usefulness 
or in popularity. It comprises everything. — Nash- 
ville Journal of Medicine and Surgery, Oct. 1893. 



compilers of Webster's Unabridged to adopt almost 
bodily its terms and definitions in the preparation 
of that great work. The derivations of words are 
clearly and fully given, thus affording facility for 
analyzing complex orcompound expressions. Its 
definitions are concise, full and satisfactory. — The 
North American Practitioner, October, 1893. 

Dunglison's Medical Dictionary has been the 
standard authority for fully sixty years. The sim- 
ple phonetic spelling placed after each word shows 
clearly how it should be pronounced. This feat- 
ure adds immeasurably to its value as a diction- 
ary. Numerous tables have been introduced, re- 
plete with valuable and practical information. 
Under Diseases is included a concise review of 
the symptomatology and treatment; under Drugs 
may be found their properties and doses, and 
under Poisoning the symptoms, antidotes and 
treatment. It has all the advantages of other 
works without their disadvantages. — The Albany 
Medical Annals, Dec. 1893. 



The National Medioal Dictionary, 

Including English, French, German, Italian and Latin Technical Terms used in 
Medicine and the Collateral Sciences, and a Series of Tables of Useful Data. By John 
S. Billings, M. D., LL. D., Edin. and Harv., D. C. L., Oxon., member of the National 
Academy of Sciences, Surgeon U. S. A., etc. In two very handsome royal octavo volumes 
containing 1574 pages, with two colored plates. Per volume — cloth, $6.00 ; leather, $7.00; 
half morocco, marbled edges, $8.50. Subscription only. Address the publishers. 

The work is remarkable for its fulness. It pres- whichmay begainedby thestudyofagooddiction- 
entsto the English reader a thoroughly scientific ary, one is enabled by the work under notice to read 
mode of acquiring a rich vocabulary and offers an intelligently any technical treatise in any of the four 
accurate and ready means of reference in consult- chief modern languages. There cannot be two 
ing works in any of the three modern continental opinions as to the great value of this dictionary as 
languages which are richest in medical literature, a book of ready reference for all sorts and condi- 
Apart from the boundless stores of information tions of medical men.— London Lancet, Apr., '90. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Anatomy, Dictionary. 



5 



NEW (THIRTEENTH) EDITION. JUST READY. 

GRAY'S ANATOMY 



N COLORS OR IN BLACK. 



Anatomy, Descriptive and Surgical, 

BY HENRY GRAY, P. R. S., 

LECTURER ON ANATOMY AT ST. GEORGE'S HOSPITAL, LONDON. 

Edited by T. PICKEKING PICK, F. E. C. S., 

Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, 
Royal College of Surgeons of England. 

A new American from the thirteenth enlarged and improved London edition. In one 
imperial octavo volume of 1118 pages, with 636 large and elaborate engravings 
on wood. Price, with illustrations in colors, cloth, $7 ; leather, $ 8. 
Price, with illustrations in black, cloth, $6 ; leather, $7. 

SINCE 1857 Gray's Anatomy has been the standard work used by students of 
medicine and practitioners in all English-speaking races. So preeminent has it 
been among the many works on the subject that thirteen editions have been 
required to meet the demand. This opportunity for frequent revisions has been 
fully utilized and the work has thus been subjected to the careful scrutiny of many of the 
most distinguished anatomists of a generation, whereby a degree of completeness and ac- 
curacy has been secured which is not attainable in any other way. In no former revision 
has so much care been exercised as in the present to provide for the student all the 
assistance that a text-book can furnish. The engravings have always formed a distin- 
guishing feature of this work, and in the present edition the series has been enriched and 
rendered complete by the addition of many new ones. The large scale on which the 
illustrations are drawn and the clearness of the execution render them of unequalled 
value in affording a grasp of the complex details of the subject. As heretofore the name 
of each part is printed upon it, thus conveying to the eye at once the position, extent 
and relations of each organ, vessel, muscle, bone or nerve with a clearness impossible 
when figures or lines of reference are employed. Distinctive colors have been utilized 
to give additional prominence to the attachments of muscles, the veins, arteries 
and nerves. For the sake of those who prefer not to pay the slight increase in cost 
necessitated by the use of colors, the volume is published also in black alone. 

The illustrations thus constitute a complete and splendid series, which will greatly 
assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room. Combining as it does a complete Atlas of Anatomy 
with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers 
a more extended range of subjects than is customary in the ordinary text-books. It not 
only answers every need of the student in laying the groundwork of a thorough medical 
education, but owing to its application of anatomical details to the practice of medicine 
and surgery, it also furnishes an admirable work of reference for the active practitioner. 



We always had a kindly regard for the illustra- 
tions in Gray, where each organ, tissue, artery, and 
nerve bear their respective names, and in this edi- 
tion color has been worked to advantage in bring- 
ing out the relationship of vessel and nerve. Of late 
years, many wor&s on an atomy have been intro- 
duced to the profession, but as a reference book 
for the practical everyday physician, and as a text- 
book for the student, we think it will be difficult 
to supplant Gray. — Buffalo Medical and Surgical 
Journal, January, 1894. 

No boob deals with the complex subject so sys- 
tematically, or presents the material in a way 
better fitted for the student to memorize. The 
reviewer can have nothing but words of praise for 
this work, which is the peer of all works on anat- 
omy. — International Medical Magazine, Dec. 1893 

For thirty-five years Gray's 'Anatomy has been 
the universal text-book for medical students and 
surgeons. Nothing but the highest praise can be 
extended in favor of this work, and continued 
success is only to be expected of a book which 
still stanos at the pinnacle of anatomical works — 
St. Louis Clinique, November, 1893. 

Apparently anatomies may come and anatomies 
may go, but this is perennially a favorite and will 



go on forever.— New York Med. Jour., Nov. 11, 1893. 

The hold which Gray's Anatomy has had upon 
generation after generation of medical students 
for nearly half a centurv remains unbroken. Dur- 
ing this time several other text-books designed to 
cover the same ground have been issued but 1 ave 
failed to take the place of the students' favorite. — 
Columbus Medical Journal, October, 1893. 

No medical student is, in our opinion, well 
equipped without a Gray's Anatomy.— Pittsburg 
Medical Review, November, 1893. 
, It embraces the whole of human anatomy, and 
it particularly dwells on the practical or applied 
part of the subject, so that it forms a most useful, 
intelligible and practical treatise for the student 
and general practitioner. — Dublin Journal of Medi- 
cal Science, December, 1893. 

Gray's Anatomy is not without competition, but 
as a text-book it is unrivalled in so many depart- 
ments that nothing is needed to commend it. — 
Physician and, Surgeon, November, 1893. 

The rapidity of sale of the work, almost unpre- 
cedented in the annals of medical literature, 
indicates that ib fulfils the requirements of the 
average medical student to perfection. — Glasgow 
Medical Journal, January, 1894. 



HOBLYN'S DICTIONARY OF MEDICINE. A Dictionary of the Terms Used in Medicine and the 
Collateral Sciences. By Richard D. Hoblyn, M. D. In one large royal 12mo. volume of 520 double- 
columned pages. Cloth, $1.50; leather, $2.00. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



6 



Anatomy, Physiology. 



HUMAN MONSTROSITIES 

BY BARTON C. HIRST, M. D., and GEORGE A. PIERSOL, M. D. s 

Professor of Obstetrics in the University Professor of Anatomy and Embryology 

of Pennsylvania. in the University of Pennsylvania. 

Magnificent folio, containing 220 pages of text, illustrated with engravings, and 
39 full- page, photographic plates from nature. In four parts, price, each, $5. Complete 
work just ready. Limited edition, for sale by subscription only. Address the Publishers. 

We have before us the fourth and last part of 
the latest and best work on human monstrosi- 
ties. This completes one of the masterpieces of 



American medical literature. Typographically 
and from an artistic standpoint, the work is un- 
exceptionable. In this last acd final volume 
is presented the most complete bibliography of 
teratological literature extant. No library will be 
complete without this magnificent work.— Jour- 
nal of the American Medical Asso., May 6, 1893. 

Altogether, Human Monstrosities is a satisfactory 
production. It will take its place as a standard 
work on teratology in medical libraries, and it 



must always retain the honor of being the first of 
its kind written in the English language. — The 
British Medical Journal, May 27, 1893. 

This work promises to be one for which a place 
must be found in the library of every anatomist, 
pathologist, obstetrician and teratologist. It is the 
joint production of an obstetrician, and an embry- 
ologist, and histologist, and this fact makes it 
certain that both the obstetric and anatomical 
sides of the subject will be fully represented and 
described. The book promises to be one of the 
greatest value to the English-speaking medical 
world— Edinburgh Medical Journal, April, 1892. 



Allen's System of Human Anatomy. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. By Harrison 
Allen, M. D., Professor of Physiology in the University of Pennsylvania. With an 
Introductory Section on Histology by E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50 ; 
also bound in one volume, cloth, $23.00 ; very handsome half Russia, raised bands and' 
open back, $25.00. For sale by subscription only. Address the Publishers. 

Holden's Landmarks, Medical and Surgical. 

Landmarks, Medical and Surgical. By Luther Holden, F. R. C. S., 
Surgeon to St. Bartholomew's Hospital, London. Second American from the third and 
revised English ed., with additions by W. W. Keen, M. D., Professor of Artistic Anatomy 
in the Penna. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00. 

Clarke & Lockwood's Dissector's Manual. 

The Dissector's Manual. By W. B. Clarke, F. B. C. S., and C. B. Lock- 
wood, F. B. C. S., Demonstrators of Anatomy at St. Bartholomew's Hospital Medical 
School, London. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. 
Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 



Messrs.Clarke and Lockwood have written a book 
that can hardly be rivalled as a practical aid to the 
dissector. Their purpose, which is "how to de- 
scribe the best way to display the anatomical 
structure," has been fully attained. They excel in 
a lucidity of demonstration and graphic terseness 
of expression, which only a long training and 



intimate association with students could have 

fiven. With such a guide as this, accompanied 
y so attractive a commentary as Treves' Surgical 
Applied Anatomy (same series), no student could 
fail to be deeply and absorbingly interested in the 
study of anatomy. — New Orleans Medical and Sur- 
gical Journal, April, 1884, 



Treves' Surgical Applied Anatomy. 

Surgical Applied Anatomy. By Frederick; Treves, F. K. C. S., Senior 
Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. In one pocket- 
size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, p. 30. 

Bellamy's Surgical Anatomy. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Begions of the Human Body, and intended as an Introduction to 
Operative Surgery. By Edward Bellamy, F. B. C. S., Senior Assistant-Surgeon to the 
Charing- Cross Hospital. In one 12mo. vol. of 300 pages, with 50 illus. Cloth, $2.25. 

Wilson's Human Anatomy. 

A System of Human Anatomy, General and Special. By Erasmus 
Wilson, F. B. S. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical 
Anatomy in the Medical College of Ohio. In one large and handsome octavo volume 
of 616 pages, with 397 illustrations. Cloth, $4.00; leather, $5.00. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
12mo., 310 pages, 220 woodcuts. Cloth, $1.76. 

HORNER'S SPECIAL ANATOMY AND HISTOL- 



OGY. Eighth edition. In two octavo volumes 
of 1007 page*, with 320 woodcuts. Cloth. S6.00. 
CLELAND'S DIRECTORY FOR THE DISSEC- 
TION OF THE HUMAN BODY. 12mo., 178 pp. 
Cloth, $1.25. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Physics, Physiology, Anatomy, Chemistry. 7 



Draper's Medical Physics. 



Medical Physics. A Text-book for Students and Practitioners of Medicine. 
By John C. Draper, M. D., LL. D., Prof, of Chemistry in the Univ. of the City of 
New York. In one octavo vol. of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 

culties to be encountered in bringing his subject 
within the grasp of the average student, and that 
he has succeeded so well proves once more that 
the man to write for and examine students is the 
one who has taught and is teaching them. The 
book is well printed and fully illustrated, and in 
every way deserves grateful recognition. — The 
Montreal Medical Journal, July, 1890. 



No man in America was better fitted than Dr. 
Draper for the task he undertook and he has pro- 
vided the student and practitioner of medicine 
with a volume at once readable and thorough. 
Even to the student who has some knowledge of 
physics this book is useful, as it shows him its 
applications to the profession that he has chosen. 
Dr. Draper, as an old teacher, knew well the diffi- 



Reichert's Physiology— Preparing. 

A Text-Book on Physiology. By Edward T. Reichert, M. D., Professor 
of Physiology in the University of Pennsylvania, Philadelphia. In one very handsome 
octavo volume of 800 pages, fully illustrated.. 

Power's Human Physiology —Second Edition. 

Human Physiology. By Henry Power, M. B., F. E. C. S., Examiner in 
Physiology, Royal College of Burgeons of England. Second edition. In one 12mo. vol. 
of 509 pp., with 68 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 30. 



Robertson's Physiological Physics. 



Physiological Physics. By J. McGregor Robertson, M. A., M. B., 
Muirhead Demonstrator of Physiology, University of Glasgow. In one 12mo. volume of 
537 pages, with 219 illus. Limp cloth, $2. See Students' Series of Manuals, page 30. 

The title of this work sufficiently explains the ments. It will be found of great value to the 
nature of its contents. It is designed as a man- practitioner. It is a carefully prepared book of 
ual for the student of medicine, an auxiliary to reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- heartily recommend it.— Journal of the American 
larly useful as a guide to his laboratory experi- Medical Association, Dec. 6, 1884. 



Dalton on the Circulation of the Blood. 

Doctrines of the Circulation of the Blood. A History of Physio- 
logical Opinion and Discovery in regard to the Circulation of the Blood. By John C. 
Dalton, M. D., Professor Emeritus of Physiology in the College of Physicians and Sur- 
geons, New York. In one handsome 12mo. volume of 293 pages. Cloth, $2. 



Dr. Dal ton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 



ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands. — New Orleans 
Medical and Surgical Journal, Aug. 1885. 



Bell's Comparative Anatomy and Physiology. 

Comparative Anatomy and Physiology. By F. Jeffrey Bell, M. A., 
Professor of Comparative Anatomy at King's College, London. In one 12mo. vol. of 561 



pages, with 229 illustrations. Limp cloth, $2. 

The manual is preeminently a student's book — 
clear and simple in language and arrangement. 
It is well and abundantly illustrated, and is read- 
able and interesting. On the whole we consider 



See Students' Series of Manuals, page 30. 
it the best work in existence in the English 
language to place in the hands of the medical 
student.— Bristol Medico- Chirurgical Journal, Mar. 



Ellis' Demonstrations of Anatomy —Eighth Edition. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy 
in University College, London. From the eighth and revised London edition. In one 
very handsome octavo volume of 716 pages, with 249 illus. Cloth, $4.25 ; leather, §5.25. 

Roberts' Compend of Anatomy. 

The Compend of Anatomy. For use in the dissecting-room and in pre- 
paring for examinations. By John B. Roberts, A. M., M. D., Lecturer in Anatomy in 
the University of Pennsylvania. In one 16mo. vol. of 196 pages. Limp cloth, 75 cents. 



WOHLER'S OUTLINES OF ORGANIC CHEM- 
ISTRY. Edited by Fittig. Translated by Ira 
Remsen, M. D , Ph. D. In one 12mo. volume of 
550 pages. Cloth, $3. 

LEHM ANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 



CARPENTER'S HUMAN PHYSIOLOGY. Edited 
bv Henry Power. In one octavo volume. 

CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
ease. With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



8 Physiology— (Continued), Chemistry. 



Foster's Physiology— New (5th) American Ed. Just Ready. 

Text-Book of Physiology. By Michael Foster, M. D., F. E. S., Prelec- 
tor in Physiology and Fellow of Trinity College, Cambridge, England. New (fifth) and 
enlarged American from the fifth and revised English edition, with notes and additions. 
In one handsome octavo vol. of 1083 pages, with 316 illus. Cloth, $4.50; leather, $5.50. 
This is the standard work on physiology, being 



most thorough and complete in all branches and 
details; moreover it contains considerable mate- 
rial which has never before been presented to the 
medical public. Evidence of its success is shown 
in the fact that it is now in its fifth English and 
fifth American edition. In its high character, in 
the care which is shown in the statements and 
their verification, and in it* thorough dealing with 
physiological ami histological problems, it is far 
ahead of any book of the class yet issued. — The 
Medical Aqe, December 26, 1893. 
The rapid exhaustion of four large American 



editions and the call for a fifth are all the in- 
troduction this valuable text-book will need. 
The work will continue to afford students and 
practitioners an ample knowledge of this funda- 
mental medical science. The Author has thor- 
oughly revised this edition with notes and addi- 
tions. The task of the American Editor has been 
mostly confined to the adaptation of the work to 
the wants of the American student, and we predict 
a large sale for it. It is now used as a text-book 
in many colleges, and the new edition with its 
many improvements will still further increase the 
popularity of the work. — Kansas City Med. Rec, '93. 



Dalton's Physiology —Seventh Edition. 

A Treatise on Human Physiology. Designed for the use of Students 

and Practitioners of Medicine. By John C. Dalton, M. D., Professor of Physiology in 
the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly 
revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beau- 
tiful engravings on wood. Cloth, $5.00 ; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never been in any doubt as to its sterling 
worth.— N. Y. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



Chapman's Human Physiology. 

A Treatise on Human Physiology. By Henry C. Chapman, M. p., 
Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 
In one octavo volume of 925 pages, with 605 engravings. Cloth, $5.50; leather, $6.50, 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine.— Buf- 
falo Medical and Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 



nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 
farther, and the latter will find entertainment and 
instruction in an admirable book of reference. — 
North Carolina Medical Journal, Nov. 1887. 



Schofield's Elementary Physiology— Just Ready. 

Elementary Physiology for Students. By Alfred T. Schofield, 
M. D., Late House Physician London Hospital. In one 12mo. volume of 380 pages, with 
227 engravings and 2 colored plates containing 30 figures. Cloth, $2.00. 

Frankland & Japp's Inorganic Chemistry. 

Inorganic Chemistry. By E. Frankeand, D. C. L., F. B. S., Professor of 
Chemistry in the Normal School of Science, London., and F. B. Japp, F. I. C, Assistant 
Professor of Chemistry in the Normal School of Science, London. In one handsome 
octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

chemical knowledge is behind the times, would 
do well to study this work. The descriptions and 
demonstrations are made so plain that there is 
no difficulty in understanding them.— Cincinnati 



This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry.with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 



Medical News, January, 1886. 



Clowes' Qualitative Analysis —Third Edition. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 

Colleges and by Beginners. By Frank Clowes, I). Sc., London, Senior Science-Master 
at the High School, Newcastle-under- Lyme, etc. Third American from the fourth and 
revised English edition, in one 12mo. vol. of 387 pages, with 55 illus. Cloth, $2.50. 



CLASSEN'S ELEMENTARY QUANTITATIVE 
ANALYSIS. Translated, with notes and addi- 
tions, by Edgar F. Smith, Ph. D., Assistant Pro- 



fessor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 
pages, with 36 illus. Cloth, $2.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Chemistry — (Continued). 



9 



Simon's Chemistry— New (4th) Edition. Just Ready. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Begin- 
ners in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medi- 
cine. By W. Simon, Ph. D., M. D., Professor of Chemistry and Toxicology in the College 
of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland Col- 
lege of Pharmacy. New (4th) edition. In one 8vo. vol. of 490 pp., with 44 woodcuts and 
7 colored plates illustrating 56 of the most important chemical tests. Cloth, $3.25. 



A work which rapidly pa <ses to its fourth edition 
needs no further proof of having achieved a suc- 
cess. In the present case the claims to favor are 
obvious. Emanating from an experienced teacher 
of medical and pharmaceutical students the vol- 
ume is closely adapted to their needs. This is 
shown not only by the careful selection and clear 
presentation of its subject matter, but by the 
colored plates of reactions, which form a unique 
feature. Every teacher will appreciate the saving 
of his own time, and the advantages accruing to 
the student from a permanent and accurate stan- 



dard of comparison for tests depending on colors, 
and frequently upon their changes. To the prac- 
titioner, who is likely to be confronted at any time 
with important pathological or toxicolcgical ques- 
tions to be answered by the test tube, the volume 
will be of the utmost value. Such it has proved 
in th°! past, and the author has accordingly been 
enabled, through frequent and thorough revisions 
to keep his work constantly in touch with the 
progress of its science and the best methods of its 
presentation.— Kansas City Medical Index, May, 
1893. 



Fownes' Chemistry —Twelfth Edition. 

A Manual of Elementary Chemistry; Theoretical and Practical. By 
George Fownes, Ph. D. Embodying Watts' Physical and Inorganic Chemistry. New- 
American, from the twelfth English edition. In one large royal 12mo. volume of 1061 
pages, with 168 engravings and a colored plate. Cloth, $2.75 ; leather, $3.25. 



Fownes' Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 



cal students. In this work are treated fully : Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
mporfcant kind, and should be familiar to every 



discoveries, the work has been revised so as to medical practitioner. We can commend the 
keep it abreast of the times. It has steadily work as one of the very best text-books upon 
maintained its position as a text-book with medi- ' chemistry extant. — Cincinnati Med. News, Oct. '85. 



Attfield's Chemistry.— Twelfth Edition. 

Chemistry, General, Medical and Pharmaceutical; Including the 
Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the 
Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., 
Ph.D., F. I.C., F. R. S., etc., Professor of Practical Chemistry to the Pharmaceutical 
Society of Great Britain, etc. A new American, from the twelfth English edition, 
specially revised by the Author for America. In one handsome royal 12mo. volume of 
782 pages, with 88 illustrations. Cloth, $2.75 ; leather, $3.25. 



Attfield's Chemistry is the most popular book 
among students of medicine and pharmacy. This 
popularity rests upon real merits. Attfield's work 
combines in the happiest manner a clear exposi- 
tion of the theory of chemistry with the practical 
application of this knowledge to the everyday 
dealings of the physician and pharmacist. His 
book is precisely what the title claims fcr it. The 
admirable arrangement of the text enables a 
reader to get a good idea of chemistry without 
the aid of experiments, and again it is a good 
laboratory guide, and finally it contains such a 



mass of well-arranged information that it will al- 
ways serve as a handy book of reference. He 
does not allow any unutilizable knowledge to slip 
into his book ; his long years of experience have 
produced a work which is both scientific and 
practical, and which shuts out everything in the 
nature of a superfluity, and therein lies the secret 
of its success. This last edition shows the marks 
of the latest progress made in chemistry and chem- 
ical teachiDg.— New Orleans Medical and Surgical 
Journal, Nov. 1889. 



Bioxam's Chemistry— Fifth Edition. 

Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professor 
of Chemistry in King's College, London. JNew American from the fifth London 
edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 



complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 
the best manuals of general chemistry In the Eng- 
lish language.— Detroit Lancet, Feb. 1884. 



Luff's Manual of Chemistry.— Just Ready. 

A Manual of Chemistry. For the use of students of medicine. By Arthur 
P. Luff, M. D., B. 8c, Lecturer on Medical Jurisprudence and Toxicological Chemistry 
St. Mary's Hospital Medical School, London. In one 12mo. vol. of 522 pages, with 36 
engravings. Cloth, $2.00. See Students' Series of Manuals, page 30. 

Greene's Medical Chemistry. 

A Manual of Medical Chemistry. For the use of Students. By William 
H. Greene, M. D., Demonstrator of Chemistry in the Medical Department of the Uni- 
versity of Pennsylvania. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



10 Chemistry — (Continued), Pharmacy. 



Vaughan & Novy on Ptomaines and Leucomaines.— 2d Edition. 

Ptomaines, Leucomaines and Bacterial Proteids ; or the Chemi- 
cal Factors in the Causation of Disease. By Victor C. Vaughan, Ph. D., 
M. D., Professor of Physiological and Pathological Chemistry, and Associate Professor of 
Therapeutics and Materia Medica in the University of Michigan, and Frederick G. 
Novy, M. D., Instructor in Hygiene and Physiological Chemistry in the University of 
Michigan. New (second) edition. In one handsome 12mo. vol. of 389 pages. Cloth, $2,25. 



This book is one that is of the greatest import- 
ance, and the modern physician who accepts 
bacterial pathology cannot have a complete 
knowledge of this subject unless he has carefully 
perused it. To the toxicologist the subject is 
alike of great import, as well as to the hygienist 



and sanitarian. It contains information which 
is not easily obtained elsewhere, and which is 
of a kind that no medical thinker should be 
without.— The American Journal of the Medical 
Sciences, April, 1892. 



Remsen's Theoretical Chemistry.— New (4th) Edition. 

Principles of Theoretical Chemistry, with special reference to the Con- 
stitution of Chemical Compounds. By Ira. Kemsen, M. D., Ph. D., Professor of Chem- 
istry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edi- 
tion. In one handsome royal 12mo. volume of 325 pages. Cloth, $2.00. 

The fourth edition of Professor Remsen's well- j-lation into German and Italian speaks for its ex- 
known book comes again, enlarged and revised, j alted position and the esteem in which it is held 
Each edition has enhanced its value. We may say | by the most prominent chemists. We claim for 
without hesitation that it is a standard work on j this little work a leading place in the chemical 
the theory of chemistry, not excelled and scarcely ! literature of this country. — The American Journal 
equalled by any other in any language. Its trans- , of the Medical Sciences, July, 1893. 

Charles' Physiological and Pathological Chemistry. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. By T. Cranstottn 
Charles, M. D., F. R S., M. S., formerly Assistant Professor and Demonstrator of Chem- 
istry and Chemical Physics, Queen's College, Belfast. In one handsome octavo volume 
of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the impor- ! nowadays. Dr. Charles has devoted much space 
tance and practical reach of his subject, and he j to the elucidation oi urinary mysteries. He does 
has treated it in a competent and instructive man- j this with much detail, and yet in a practical and 
ner. We cannot recommend a better book than j intelligible manner. In fact, the author has filled 
the present. In fact, it fills a gap in medical text- ! his book with many practical hints.— Medical Eec- 
books, and that is a thine which can rarely be said | ord, December 20, 1884. 



Hoffmann aid Powers' Medicinal Analysis. 

A Manual of Chemical Analysis, as applied to the Examination of Medi- 
cinal Chemicals and their Preparations. Being a Guide for the Determination of their 
Identity and Quality, and for the Detection of Impurities and Adulterations. For the 
use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceu- 
tical and Medical Students. By Frederick Hoffmann, A. M., Ph. D., Public Analyst to 
the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem- 
istry in the Philadelphia College of Pharmacy. Third edition, entirely rewritten and 
much enlarged. In one octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

Parrish's Pharmacy —Fifth Edition. 

A Treatise on Pharmacy : Designed as a Text-book for the Student, and as 
a Guide for the Physician and Pharmaceutist. With many Formula? and Prescriptions. 
By Edward Parrish, late Professor of the Theory and Practice of Pharmacy in the 
Philadelphia College of Pharmacy. Fifth edition, thoroughly revised, by Thomas S. 
Wiegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. 
Cloth, $5.00; leather, $6.00. 

Caspari's Pharmacy —Preparing. 

A Text-Book on Pharmacy, for Students and Pharmacists. By 

Chardes Caspari, Jr., Ph. G., Professor of the Theory and Practice of Pharmacy in the 
Maryland College of Pharmacy, Joint Editor of The National Dispensatory of 1894. In 
one very handsome octavo volume, richly illustrated. 

Ralfe's Clinical Chemistry. 

Clinical Chemistry. By Charles H. Kalfe, M. D., F. R C. P., Assistant 
Physician at the London Hospital. In one pocket-size 12mo. volume of 314 pages, 
with 16 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



flateria fledica, Therapeutics. 



11 



JUST READY— NEW AND THOROUGHLY REVISED EDITION. 

The National Dispensatory. 

Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi- 
cines, including those recognized in the Pharmacopoeias of the United States, Great 
Britain and Germany, with numerous references to the French Codex. By Alfred 
Stii/le, M. D., LL. D., Professor Emeritus of the Theory and Practice of Medicine and of 
Clinical Medicine in the University of Pennsylvania, John M. Maisch, Phar. D., late 
Professor of Materia Medica and Botany in Philadelphia College of Pharmacy, Secretary 
to the American Pharmaceutical Association, Charles Caspari, Jr., Ph. G., Professor 
of Pharmacy in the Maryland College of Pharmacy, Baltimore, and Henry C. C. Maisch, 
Ph. G., Ph. D. New (fifth) edition, thoroughly revised in accordance with the new U. S. 
Pharmacopoeia (Seventh Decennial Kevision, 1894.) In one magnificent imperial octavo 
volume of 1910 pages, with 320 engravings. Cloth, $7.25, leather, $8.00. With Eeady 
Keference Thumb- letter Index, cloth, $7.75 ; leather, $8.50. 

ON the first appearance of The National Dispensatory fifteen years ago it was at once 
recognized by the pharmaceutical and medical professions as satisfying the need 
for a work affording all necessary information upon its subject, with authoritative 
accuracy, and with a completeness and convenience attainable only by the exclusion of 
obsolete matter. Its success in filling this want is fully attested by the rapid demand for 
five edition 5 *, and the opportunity thus afforded has been well used in successive revisions, 
each placing it abreast of the day and maintaining the characteristics which had won for 
it a leading position. 

Of all its issues the present embodies the results of the most exhaustive revision. 
The sweeping changes in the new United States Pharmacopoeia are thoroughly incorpor- 
ated, with official authorization of the Committee of Ee vision, and full use has been made 
of all valuable material in the latest issues of foreign Pharmacopoeias. The volume is 
accordingly rich in pharmaceutical and chemical information, with data, formulas, tables, 
etc., gathered from all official sources, but this constitutes only a single department of its 
usefulness. As an encyclopedia of the latest and best therapeutical knowledge it deals 
not only with all official drugs, but also with all the new synthetic remedies of value 
and with the unofficial preparations now so largely in use. Pharmacists will appreciate 
its systematic descriptions of the materia medica, it clear explanations of chemical and 
pharmaceutical processes and tests, and its illustrations of important drugs and of the 
most improved apparatus. Physicians will readily perceive the indispensable assistance 
offered by its authoritative statements as to the efficacy of drugs in the light of the most 
recent medical advances. Arranged alphabetically in the text, this information is 
placed most suggestively at command by the recommendations grouped under the various 
Diseases in the Therapeutical Index. Together with the General Index this covers more 
than one hundred treble-columned pages containing 25,000 references. The immensity 
of detail comprised in this single volume of 1900 pages is thus most forcibly indicated. 
Though the present edition contains far more matter than its predecessor it is maintained 
at the same price in view of the ever- increasing demand. Weights and Measures are 
given in both Ordinary and Metric Systems. 

In brief the new edition of The National Dispensatory is presented to the medical 
and pharmaceutical professions as the equivalent of a whole library of pharmaceutical and 
therapeutic information ; it is the standard of accuracy, the embodiment of completeness 
without inconvenient bulk, and a marvel of cheapness owing to the widespread demand 
for it as the authority. 



Maisch's Materia Medica— Fifth Edition. 

A Manual of Organic Materia Medica ; Being a Guide to Materia Medica 
of the Vegetable and Animal Kingdoms. For the Use of Students, Druggists, Pharmacists 
and Physicians. By John M. Maisch, Phar. D., Prof, of Materia Medica and Botany in 
the Philadelphia College of Pharmacy. New (fifth) edition, thoroughly revised. In one 
very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth, $3.00, 



This is an excellent manual of organic materia 
medica, as are all the works that emanate from the 
skilful pen of such a successful teacher as John 
M. Maisch. The book speaks for itself in the most 
forcible language. In the edition before us which 
is the fifth one published within the comparatively 
short space of eight years (and this is the best 
proof of the great value of the work and the 
iust favor with which it has been received and 
accepted), the original contents have been thor- 
oughly revised and much good and new matter 
has been incorporated. We have nothing but praise 
for Professor Maisch's work. It presents no weak 



point, even for the most severe critic. The book 
fully sustains the wide and well-earned reputa- 
tion of its popular author. In the special line of 
work of which it treats it is fully up to the most 
recent observations and investigations. After a 
careful perusal of the book, we do not hesitate to 
recommend Maisch's Manual of Organic Materia 
Medica as one of the best, if not the best work on 
the subject thus far published. Its usefulness 
cannot well be dispensed with, and students, drug- 
gists, pharmacists and physicians should all pos- 
sess a copy of such a valuable book. — Medical 
News, December 31, 1892. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



12 Therapeutics, flateria fledica — (Continued). 



A System of Practical Therapeutics 

BY AHERICAN AND FOREIGN AUTHORS. 
Edited by HOBART AilORY HARE, H. D. 

Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. 

In a series of contributions by seventy-eight eminent authorities. In three large 
octavo volumes of 3544 page?, with 434 illustrations. Price, per volume: Cloth, $5.0.0; 
leather, $6.00 ; half Russia, $7.00. For sale by subscription only. Address the Publishers. 
Full prospectus free to any address on application. 



The various divisions have been elaborated by- 
men selected in view of their special fitness. In 
every case there is to be found a clear and concise 
description of the disease under consideration, 
corresponding with the most recent and well- 
established views of the subject, embracing appo- 
site pictorial illustrations where these are neces- 
sary. In treating of the employment of remedies 
and therapeutical measures, the writers have 
been singularly happy in giving in a definite way 
the exact methods employed and the results ob- 
tained, both by themselves and others, so that one 
might venture with confidence to use remedies 
with which he was previously entirely unfamiliar. 
The practitioner could hardly desire a book on 
practical therapeutics which he could consult with 
more interest and profit. — The North American 
Practitioner, September, 1892. 

The scope of this work is beyond that of any 
previous one on the subject. The goal, after all, 



is the treatment of disease, and a work which con- 
tributes to its successful management is to be 
looked upon as of vast use to humanity. It can- 
not be denied that therapeutic resources, whether 
the treatment be confined to the mere administra- 
tion of drugs, or allowed its more extended appli- 
cation to the management of disease, have so 
greatly multiplied within the last few years as to 
render previous treatises of little value. Herein 
will be found the great value of ri are's encyclo- 
pedic work, which groups together within a single 
series of volumes the most modern methods 
known in the management of disease, and espe- 
cially deals with important subjects comprehen- 
sively, which could not be done in a more limited 
treatise. We cannot commend Hare's System 
of Practical Therapeutics too highly; it stands 
but first and foremost as a work to be consulted 
by authors, teachers, and physicians, throughout 
the world. — Buffalo Med. and tiurg. Jour., Aug. 1892. 



Hare's Text-Book of Practical Therapeutics —New (3d) Ed. 

A Text-Book of Practical Therapeutics ; With Especial Reference to 
the Application of Remedial Measures to Disease and their Employment upon a Rational 
Basis. By Hobart Amoey Hare, M. D., Professor of Therapeutics and Materia Medica 
in the Jefferson Medical College of Philadelphia ; Sec. of Convention for Revision of U. S. 
Pharmacopoeia of 1890. With special chapters by Drs. G. E. de Schweinitz, Edward 
Martin, J. Howard Reeves and Barton C. Hirst. New (3d) and revised edition. 
In one octavo volume of 689 pages. Cloth, $3.75 ; leather, $4.75. 

The student of other works, has often, indeed, I presented with notes as to its usefulness in numer- 
very often, longed for less of the abstract materia I ous diseases, while in the latter each disease is 



medica and more of the practical application of 
drugs to disease. In this work that want is filled. 
The drugs are arranged alphabetically, which 
enables one to find any name quickly, and, with 
the excellent index at the end of the volume, 
naught is left to be desired in the way of quick 
reference. Each drug, including all the newer 
remedies which have been proved to possess true 
merit, is considered in a rational and scientific 
manner. This work also presents us with nearly 
250 pages of practical therapeutics, as applied 
to the individual diseases. The subjects are 
arranged alphabetically. It is in the chapter on 
Diseases that the student finds the rationale of 
therapeutics. This section is properly the com- 
plement of the former, in which each drug was 



considered very fully from a therapeutical stand- 
point, the applications and special indications of 
the different remedies in the different phases of 
that particular affection being given. It is not a 
wonder that this work was quickly adopted by 
many colleges as a text-book and so liberally pur- 
chased as to necessitate the publication of a third 
edition within two years. The student will find 
its pages filled with the choicest of therapeutical 
lore, systematically arranged and clearly and forci- 
bly presented ; the practitioner will appreciate its 
rationality and its general utility as an elbow con- 
sultant. It contains, without question, the best 
exposition of modern therapeutics of any text- 
book with which we are acquainted. — The Chicago 
Clinical Review, March, 1893. 



Edes' Therapeutics and Materia Medica. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. By Robert T. Edes, M. D., Jackson Professor of 
Clinical Medicine in Harvard University. Octavo, 544 pp. Cloth, $3.50 ; leather, $4.50. 



It possesses all the essentials which we expect 
in a book of its kind, such as conciseness, clear- 
ness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated ot. The clinical index at 
the end will be found very useful. We heartily 
commend the book and congratulate the author 



on having produced so good a one.— N. T. Medical 
Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action. — Pharmaceutical Era, Jan. 1888. 



Bruce's Materia Medica and Therapeutics.— Fourth Edition. 

Materia Medica and Therapeutics. An Introduction to Kational Treat- 
ment. By J. Mitchell Bruce, M. D., F. E. C. P., Physician and Lecturer on Materia 
Medica and Therapeutics at Charing-Cross Hospital, London. Fifth edition. In one 
12mo. volume of 591 pages. Cloth. $1.50. See Students' Series of Manuals, page 30. 

part of the book contains an outline of general 
therapeutics, each of the symptoms of the body 
being taken in turn, and the methods of treat- 



The pharmacology and therapeutics of each drug 
are given with great fulness, and the indications for 
its rational employment in the practical treatment 
of disease are pointed out. The Materia Medica 
proper contains all that is necessary for a medical 
student to know at the present day. The third 



ment illustrated. A lengthy notice of a book so well 
known is unnecessary.— Med. Chronicle, May, 1891. 



Lea Brothers & Co., Pub fishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine, 



13 



Flint's Practice of Medicine— Sixth Edition. 

A Treatise on the Principles and Practice of Medicine. Designed 
for the use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., 
Professor of the Principles and Practice of Medicine, and of Clinical Medicine in Belle- 
vue Hospital Medical College, N. Y. Sixth edition, thoroughly revised and rewritten 
by the Author, assisted by William H. Welch, M. D., Professor of Pathology, 
Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. L\, LL. D., Professor 
of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome octavo 
volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6,50. 

in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and aa 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art.— Cincinnati Medical News, Oct. 1886. 



No text-book on the principles and practice of 
medicine has ever met in this country with such 
general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 



Hartshorne's Essentials of Practice —Fifth Edition. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. By Henry Hartshorne, M. D., LL. D., lately Professor 
of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and 
rewritten. In one 12mo. vol. of 669 pages, with 144 illus. Cloth, $2.75 ; half leather, $3. 



Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen.— Olasgoiv Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 



a better average of actual practical treatment than 
this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials are most valuable in affording the means to 
see at a glance the whole literature of any disease, 
and the most valuable treatment.— Chicago Medical 
Journal and Examiner, April, 1882. 



Farquharson's Therapeutics and Materia Medica — 4th Ed. 

A Guide to Therapeutics and Materia Medica. By Robert Far- 
quharson, M. D., F. R. C. P., LL. D., Lecturer on Materia Medica at St. Mary's Hospi- 
tal Medical School, London. Fourth American, from the fourth English edition. 
Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Pro- 
fessor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chi- 
rurgical College of Philadelphia. To one handsome 12mo. vol. of 581 pp. Cloth, $2.50. 

It may correctly be regarded as the most modern copceias, as well as considering all non-official but 
work of its kind. It is concise, yet complete, important new drugs, it becomes in fact a miniature 
Containing an account of all remedies that have dispensatory. — Pacific Medical Journal, June, 1889. 
a place in the British and United States Pharma- 



Cohen's Applied Therapeutics. 

A Handbook of Applied Therapeutics. Being a Study of Principles 
Applicable and an Exposition of Methods Employed in the Management of the Sick. 
By Solomon Solts Cohen - , M. D., Prcfessor of Clinical Medicine and Applied Thera- 
peutics in the Philadelphia Polyclinic. In one large 12mo. vol., with illus. Preparing. 



REYNOLDS' SYSTEM OF MEDICINE. Edited 
by J. Russell Reynolds, M. D., Professor of ttie 
Principles and Practice of Med. in University 
College, London. With notes and additions by 
Henry Hartshorne, A. M., M. D., late Professor 
of Hygiene in the University of Pennsylvania. 
Three octavo volumes, r^ntaining 3056 donble- 
columned pages, with 317 illustrations. Price 
per volume, cloth, $5.00; sheep, $6.00; half 
Russia, $6.50. Subscription only. 

WATSON'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF PHYSIC. From the fifth 
English edition. Edited with additions, and 190 
illustrations, by Henry Hartshorne, A.M., M. D., 
late Professor of Hygiene in the University of 
Pennsylvania. In two large octavo volumes of 
1840 pages. Cloth, $9.00; leather, $11.00. 

FLINT ON PHTHISIS: ITS MORBID ANAT- 
OMY, ETIOLOGY, SYMPTOMATIC EVENTS 
AND COMPLICATIONS, FATALITY AND 
PROGNOSIS, TREATMENT AND PHYSICAL 
DIAGNOSIS; in a series of Clinical Studies. In 
one octavo volume of 442 pages. Cloth, $3.50. 

FLINT'S PRACTICAL TREATISE ON THE 
DIAGNOSIS, PATHOLOGY AND TREATMENT 
OF DISEASES OF THE HEART. Second re- 
vised and enlarged edition. In one octavo vol- 
ume of 550 pages, with a plate. Cloth, $4. 



FLINT'S ESSAYS ON CONSERVATIVE MEDI- 
CINE AND KINDRED TOPICS. In one very 
handsome royal 12mo. volume of 210 pages. 
Cloth, $1.38. 

k TREATISE ON FEVER. By Robert D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. 

LECTCTRF.S ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages, tlloth, $2.50. 

LA ROCHE ON YELLOW FEVER, in its Histori- 
cal, Pathological, Etiological and Therapeutical 
Relations. Two octavo vols., 1468 pp. Cloth, $7.00. 

BRUNTON'S PHARMACOLOGY, THERAPEU- 
TICS AND MATERIA MEDICA. Octavo, 1305 
pages, 230 illustrations. 

HERMANN'S EXPERIMENTAL PHARMACOL- 
OGY. A Handbook of Methods for Determining 
the Physiological Action of Drugs. Translated, 
with the Author's permission, and with exten- 
sive additions, by R. M. Smith, M. D. 12mo., 
199 pag^s, with 32 illustrations. Cloth. $1.50. 

STiLLE'S THERAPEUTICS AND MATERIA 
MEDICA. A Systematic Treatise on the Action 
and Uses of Medicinal Agents, including their 
Description and History. Fourth edition, re- 
vised and enlarged. In two octavo volumes, con- 
taining 1936 pages. Cloth, $10.00 ; leather, $12.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



14 Prac. of fledicine, Treatment, Digestive Syst. 



Lyman's Practice of Medicine. 

The Principles and Practice of Medicine. For the Use of Medical 
Students and Practitioners. By Henry M. Lyman, M. D., Professor of the Principles 
and Practice of Medicine, Rush Medical College, Chicago. In one very handsome octavo 
volume of 925 pages, with 170 illustrations. Cloth, $4.75 ; leather, $5.75. 



This is an excellent treatise on the practice of 
medicine, written by one who is not only familiar 
with his subject, but who has also learned through 
practical experience in teaching, what are the 
needs of the student, and how to present the facts 
to his mind in the most readily assimilable form. 
Although the book contains over nine hundred 

Eages, there has been no space wasted by useless 
istorical essays, prolonged discussions on de- 
batable topics, or "padding" of any kind. Each 
subject is taken up" in order, treated clearly but 
briefly, and dismissed when all has been said that 
need be said in order to give the reader a clean- 
cut picture of the disease under discussion. The 
reader is not confused by having presented to him 
a variety of different methods of treatment, among 
which he is left to choose the one most easy of exe- 
cution, but the author describes the one which is, 
in his judgment, the best. This is as it should be. 



What the student should be taught is the one 
most approved method of treatment. We have 
spoken of the work as one for the student, and 
this because the author occupies so prominent a 
position as a teacher, but we would not be under- 
stood that it is adapted only for students. There 
is many a practitioner of ten years' or more stand- 
ing, who has been unable to follow the constant 
advances made in medical science, to whom this 
work will be of great use. He will find here each 
subject presented in its latest aspect, and only 
such theories mentioned as have been generally 
accepted by the highest authorities. The practi- 
cal and busy man who wants to ascertain in a 
short time all the necessary facts concerning the 
pathology or treatment of any disease, will find 
here a safe and convenient guide.— Medical Rec- 
ord, October 22, 1892. 



The Year-Book of Treatment for 1894— Ready Very Shortly. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine and Surgery. In one 12mo.vol. of 501 pages. Cloth, $1.50. 

For special commutations with periodicals see pages 1 and 2. 
A notice cf the previous edition is appended. 



The Year- Book of Treatment easily holds its 
advanced place among the many annuals and 
abstracts forming so marked a feature of mod- 
ern medical literature. Its pages give a critical 
and well-arranged review of the best that the 
year has brought forth in all departments of ther- 



apeutics. Among so much that is excellent one 
can scarcely choose. Commendable features are 
the Summary of Therapeutics and the Selected 
List of New Books. There is as usual a good 
index. — The Medical News. 



The Year-Books of Treatment for 1891, 1892 and 1893. 

12mos., 485 pages. Cloth, $1.50 each. 

The Tear-Books of Treatment for 1886 and 1887. 

Similar to above. 12mos., 320-341 pages. Cloth, $1.25 each. 



A System of Practical Medicine. 

B Y AMERICAN A UTHOBS. 
Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, $7. Subscription only. 



* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, July 26, 1886. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 



lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome of 
American brains, and is marked throughout by 
much of the sturdy independence of thought and 
originality that is a national characteristic. Yet no- 
where is there lack of study of the most advanced 
views of the day.— N. C. Med. Jour., Sept. 1886. 



Habershon on the Abdomen. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. By 
S. O. Habershon, M. D., Senior Physician to and late Lecturer on Principles and Prac- 
tice of Medicine at Guy's Hospital, London. Second American from third enlarged and 
revised English edition. In one handsome octavo vol. of 554 pages, with illus. Cloth, $3.50. 

This valuable treatise on diseases of the stomach rectum. A fair proportion of each chapter is 
and abdomen will be found a cyclopaedia of infor- devoted to symptoms, pathology, and therapeutics, 
mation, systematically arranged, on all diseases of — New York Medical Journal, April, 1879. 
the alimentary tract, from the mouth to the 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine. Diagnosis, Heart. 15 



fflusser's Medical Diagnosis— Just Ready. 

A Practical Treatise on Medical Diagnosis For the Use of Students 
and Practitioners. By John H. Musser, M. D., Assistant Professor of Clinical Medicine, 
University of Pennsylvania, Philadelphia. In one very handsome octavo volume of 873 
pages, with 162 illustrations. Cloth, $5 ; leather, $6. 

Great care has been bestowed on this book by its eminent author in the endeavor 
to make it a thorough explanation of a department of medicine which underlies the 
whole science of treatment. Everything pertaining to the diagnosis of disease — physi- 
cal, rational, bacteriological — will here be found in the latest and most approved form. 
The work is one on which students and practitioners can confidently depend for an ample 
working knowledge of this fundamental branch of medicine. 

Flint on Auscultation and Percussion —Fifth Edition. 

A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis 
of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D., 
LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi- 
cal College, New York. Fifth edition. Edited by James C. Wilson, M. D., Lecturer 
on Physical Diagnosis in the Jefferson Medical College, Philadelphia. In one hand- 
some royal 12mo. volume of 274 pages, with 12 illustrations. Cloth, $1.75. 

oughness of Prof. Flint's investigations. For stu- 
dents it is excellent. Its value is shown both in 
the arrangement of the material and in the clear, 
concise style of expression. For the practitioner 
it is a ready manual for reference. — North Ameri- 



This little book through its various editions has 
probably done more to advance the science of 

Shysical exploration of the chest than any other 
issertation upon the subject, and now in its fifth 
edition it is as near perfect as it can be. The 
rapidity with which previous editions were sold 
shows how the profession appreciated the thor- 



can Practitioner, January, 1891. 



Wliitla's Dictionary of Treatment. 

A Dictionary of Treatment ; or Therapeutic Index, including 
Medical and Surgical Therapeutics. By William Whitla, M. D., Professor 
of Materia Medica and Therapeutics in the Queen's College, Belfast. Eevised and adapted 
to the United States Pharmacopoeia. In one square, octavo vol. of 917 pp. Cloth, $4.00. 



"We have already dictionaries of medicine and 
dictionaries of surgery; Dr. Whitla now provides 
us with a dictionaryof treatment. And reference 
to the volume shows that it really is what it 
professes to be. The several diseased condi- 
tions are arranged in alphabetical order, and 
the methods — medical, surgical, dietetic, and 
climatic— by which they may be met, considered. 
On every page we find clear and detailed direc- 
tions for treatment supported by the author's 
personal authority and experience whilst the 
recommendations of other competent observers 
are also critically examined. The book abounds 
with useful, practical hints and suggestions, and 



tha younger practitioner will find in it exactly the 
help he so often needs in the treatment both of 
t^ose who are ill, and those who are ailing. At the 
same time the most experienced members of the 
profession may usefully consult its pages for the 
purpose of learning what is really trustworthy in 
the later therapeutic developments. The Diction- 
ary is, in short, the recorded experience of a prac- 
tical scientific therapeutist, who has carefully 
studied diseases and disorders at the bed-side and 
in the consulting-room, and has earnestly ad- 
dressed himself to the cure and relief of his 
patients. — The Glasgow MedicalJournal, April, 1892. 



Fottaergill's Handbook of Treatment.— Third Edition. 

The Practitioner's Handbook of Treatment ; Or, The Principles of 
Therapeutics. By J. Milner Fothergill, M. D., Edin., M. B. C. P., Lond., Physician 
to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. 
volume of 661 pages. Cloth, $3.75 ; leather, $4.75. 



This is a wonderful book. If there be such a 
thing as "medicine made easy," this is the work to 
accomplish this result. — Va. Med. Month., June,'87. 

To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment qf its morbid conditions brought 
together in a single chapter, and the relations 
bet ween the two clearly stated, cannot fail to prove 



a great convenience to many thoughtful but busy 
physicians. The practical value of the volume is 
greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition.— N. Y. Med. Jour., June 11,'87. 



Broadbent on the Pulse. 

The Pulse. By W. H. Broadbent, M. D., F. E. C. P., Physician to and Lecturer 
on Medicine at St. Mary's Hospital, London. In one 12mo. volume of 312 pages. 
Cloth, $1.75. See Series of Clinical Manuals, page 30. 



TANNER'S MANUAL OF CLINICAL MEDICINE 
AND PHYSICAL DIAGNOSIS. Third American 
from the second London edition. Revised and 
enlarged by Tilbury Fox, M. D. In one 12mo. 
volume of 362 pp. with illus. Cloth, $1.50. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis. 
M. D. Edited by Frank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, $1.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth. 82.50. 

FLINT'S PRACTICAL TREATISE ON THE 
PHYSICAL EXPLORATION OF THE CHEST 



AND THE DIAGNOSIS OF DISEASES AF- 
FECTING THE RESPIRATORY ORGANS. 
Second and revised edition. In one handsome 
octavo volume of 591 pages. Cloth, $4.50. 

STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 

HOLLAND'S MEDICAL NOTES AND REFLEC* 
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson* Street, Philadelphia. 



16 Practice, Electricity, Cholera, Food, Hygiene. 



Yeo's Medical Treatment.— Just Ready. 

A Manual of Medical Treatment or Clinical Therapeutics. By 

1. Burney Yeo, M. D., F. E. C. P., Prof, of Clinical Therapeutics in Kind's Coll., London. 
In two 12mo. volumes containing 1275 pages, with illustrations. Cloth, $5.50. 

This work is devoted entirely to the treatment 
of disease, being the first we have ever seen of the 
kind. Only so much of the pathology and etiol- 



ogy of disease is introduced as is necessary to ar- 
rive at the rational indications, without which the 
administration of a drug can hardly be called 
scientific. Half a dozen choice* formulae by lead- 
ing physicians are appended to each chapter. 
The index is so arranged that one can find disease 
and the various remedies at a glance. Without 
exaggeration, we can say that one could hardly 
read anything affording at the same time so much 

Eleasure ana profit as this elegantly written and 
eautifuhy printed book. — The Canada Medical 
Record, November, 1893. 

In Dr. Yeo's book the study of the treatment of 
disease is approached, not from the side of the 
drug or remedy as in works on therapeutics, but 
"from the side of the disease." The various dis- 
eases are grou ped together, a short account is given 
of the clinical history, course and pathology of 
each, and from a consideration thereof, indications 
for treatment are arrived at; then follows a full dis- 



cussion of the best methods of carrying out these 
indications. Each section contains a number of 
prescriptions which the author has found most 
useful, and at the end of every chapter is added a 
selection of formulae from the writings of various 
well-known physicians. The work is exceedingly 
practical, and the details of the various methods 
of treatment are always given. Full directions are 
given with regard to diet, mode of life, and gen- 
eral treatment, wh'ch are often as important as the 
treatment by drugs.— Med. Chronicle, January, 1894. 

The discussion of the different ailments has a 
distinctly practical turn toward the main purpose 
of the book. Standard formulae are introduced 
from eminent practitioners, and all the drugs of 
recognized value are grouped in the order of their 
importance. The dosage r cei^es careful atten- 
tion, which is a feature that cannot be too highly 
commended. It cannot fail to be* an exceedingly 
useful, suggestive and instructive work to the 
physician who wishes to be well up ia the present 
advanced and scientific therapeutics of the day. — 
Medical Record, November 25, 1893. 



Yeo on Food in Health and Disease. 

Food in Health and Disease. By I. Burney Yeo, M. D., F. E. C. P., 

Professor of Clinical Therapeutics in King's College, London In one 12mo. volume of 
590 pages. Cloth, $2 00. See Series of Clinical Manuals, page 30. 



Dr. Yeo supplies in a compact form nearly all that 
the practitioner requires to know on the subject of 
diet. The work is divided into two parts— food in 
health and food in disease. Dr. Yeo has gathered 
together from all quarters an immense amount of 
useful information within a comparatively small 



compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo.— British Medical 
Journal, Feb. 8, 1890. 



Bartliolow on Electricity in Medicine and Surgery —3d Ed. 

Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. By Koberts Bartholow, A. M., M. D., LL. D., Emeritus Pro- 
fessor of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila- 
delphia, etc. Third edition. In one octavo volume of 308 pp., with 110 illus. Cloth, $2.50. 

Bartholow on CMera — Just Ready. 

Cholera : Its Causes, Symptoms, Pathology and Treatment. By 

Roberts Bartholow, M. D., LL. D., Emeritus Professor of Materia Medica, General 
Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia. In one 12mo. 
volume of 127 pages, with 9 illustrations. Cloth, $1.25. 

pathology of the disease are described separ- 
ately in a brief and comprehensive manner. The 
final chapter, on the treatment of cholera, gives 
the prophylactic measures, including quarantine 
and the latest therapeutical methods in vogue in 
India, Europe and America The volume is writ- 
ten in the author's usual pleasant style, and will 
satisfy the desire of any one that wishes to obtain 
the most recent information on the subject. — The 
New York Medical Journal, July 29, 1893. 



The most scientific work on cholera extant. 
Broad yet comprehensive, concise but explicit, it 
treats the subject in a way to invite but little criti- 
cism. The most valuable chapter is the one on 
treatment, which, considering the author's thera- 
peutical experience, and the great improvements 
made ;n practice, is indeed, a contribution to 
medical literature worthy of more than pnssing 
notice - The Mtdical Fo< tnightly, July 15 1893. 

The author has sought to make a practical book 
in the smallest compass. The symptoms and 



Richardson's Preventive Medicine. 

Preventive Medicine. By B. W. Kichardson, M. D., LL. D., F. E. S., Fel- 
low of the Royal Coll. ot Pbys., London. In one 8vo. voJ. ot 729 pp. Cloth, $4; leather, $5. 

scholarly ; the discussion of the question of disease 
is comprehensive, masterly and fully abreast with 
the latest and best knowledge on the subject, and 



There is perhaps no similar work written for 
the general public that contains such a complete, 
reliable and instructive collection of data upon 
the diseases common to the race, their origins, 
causes, and the measures for their prevention. 
The descriptions of diseases are clear, chaste and 



the preventive measures advised are accurate, 
explicit and reliable.— The American Journal of the 
Medical Sciences, April, 1884. 



SCHREIBER'S MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EX- 
ERCISE. Translated by Walter Mendelson, 
M. D., of New York; In one 8vo. volume of 274 
pp., with 117 engravings. 

STTLLE ON CHOLERA: Its Origin, History, 
Causation, Symptoms, Lesions, Prevention and 
Treatment. In one handsome 12mo. volume of 
163 pages, with a chart. Cloth, $1.25. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, 82.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 
M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, $2.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Throat, Nose, Lungs, Hind, Nerves. 17 



Seller on the Throat and Nose— New (4th) Ed. 

A Handbook of Diagnosis and Treatment of Diseases of the 
Throat* Nose and Naso-Pharynx. By Carl Seiler, M. D., Lecturer on 
Laryngoscopy in the University of Pennsylvania. New (4th) edition. In one handsome 
12rao. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25. 

This little book is eminently practical, and will 
prove of interest not only to the specialist, but to 
the general practitioner as well. It deals with the 
subject in a clear and distinct manner, and the 
text is copiously illustrated with diagrams and 
colored plates. So little attention is paid ordi- 
narily to the examination of the larynx that the 
need of such a book has long been felt. By con- 
sulting its pages anyone can learn the necessary 
manipulations, and, by a litt'e practice, soon be- 
come expeit in the use of the laryngeal mirror, a 
method of examination too often neglected. The 
anatomy of the larynx is explained with especial 
care, and the operative procedures for various 
diseases of the throat, tonsils, etc., are carefully 
explained. Approved methods of tieatment are 
dealt with in a very satisfactory way, and a 1 the 
most useful remedial agents are described. — 



International Medical Magazine, November, 1893. 

As a guide to the practitioner and a text-book 
for the student, it is unexcelled, being plain, ac- 
curate, comprehensive and pleasantly written. — 
Atlanta Medical and Surgical Journal, August, 1893. 

It is needless to say that it is brought up to date 
in the fullest possible sense of the term. Rarely 
has any treatise on any specialty met with a more 
cordial reception than the one under consider- 
ation. A most generous recognition is given to 
the work of American laryngologists. The main 
feature of the present edition has been the ex- 
pansion of that portion which deals with the 
diseases of the nose. The author is to be com- 
mended on the excellence of his work, and con- 
gratulated that a new edition has been so speedily 
called for. — Medical Record, November 25, 1893. 



Browne on the Throat and Nose —New (4th) Ed. Just Ready. 

The Throat and Nose and Their Diseases. By Lennox Browne, 
F. B. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. 
Fourth and enlarged edition. In one imperial octavo volume of 751 pages, with 120. 
illustrations in color, and 235 engravings on wood. Cloth, $6.50. 



Although quite complete enough for the use of 
specialists, it is at the same time so clear as to be 
of daily value to the general practitioner, who will 
find at the end of the voiume a number of well- 
tried formulas most in vogue at the London hos- 

Sitals for diseases of the throat — The Canada 
ledical Record, November, 1893. 



It is an admirable presentation of its subject in 
the light of the large clinical experience of a care- 
ful observer. It is a book that no specialist can 
afford not to have, and that the general physician 
can rely upon as a safe guide and practical adviser. 
— The Medical News, Oct. 14, 1893. 



Tuke on the Influence of the Mind on the Body. 

Illustrations of the Influence of the Mind upon the Body in 
Health and Disease. Designed to elucidate the Action of the Imagination. By 
Daniel Hack Tuke, M. D., Joint Author of the Manual of Psychological Medicine, 
etc. New edition. Thoroughly revised and rewritten. In one 8vo. volume of 467 pages, 
with 2 colored plates. Cloth, $3 00. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomenathe more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal, September 6, 1884. 



(Houston on Mental Diseases. 

Clinical Lectures on Mental Diseases. By Thomas S. Clouston^ 
M. D., Lecturer on Mental Diseases in the University of Edinburgh. With an Appen- 
dix, containing an Abstract of the Statutes of the United States and of the Several 
States and Territories relating to the Custody of the Insane. By Charles F. Folsom, 
M. D., Ass't Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one octavo 
volume of 541 pages, with eight lithographic plates, four of which are colored. Cloth, $4. 
JI^'Dr. Folsom's Abstract also separate, in one 8vo. vol. of 108 pages Cloth, $1.50. 



The descriptions of the diseases and cases are 
simple and practical, but true; and one sees as he 
reads that they are given by one perfectly familiar 
from daily observation with the cases and disease 



and descriptions given as to the practical man- 
agement and care of the cases. We can heartily 
recommend it to the student and busy general 
practitioner. Dr. Folsom's work greatly increases 



he is speaking of. One feature of the book which the value of Dr. Clouston's book for the American 
commends it highly, and which is not to be found practitioner. — Archives of Medicine, June, 1884. 
in any other work on mental diseases, is the hints | 

Playfair on Nerve Prostration and Hysteria. 

The Systematic Treatment of Nerve Prostration and Hysteria. 

By W. S. Playfair, M. D., F. B. C. P. In one 12mo. volume of 97 pages. Cloth, $1.00. 



BROWNE ON KOCH'S REMEDY IN RELATION 
TO THROAT CONSUMPTION. In one octavo 
volume of 121 pages, with 45 illustrations, 4 of 
which are colored, and 17 charts, Cloth, $1.50. 

FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 



valence in various Countries. Second and revised 
edition. In one 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH ON CONSUMPTION ; its Early and Reme- 
diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its- 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



18 Nervous and Flental Diseases, Histology. 
Gray on Nervous and Mental Diseases. 

A Practical Treatise on Nervous and Mental Diseases. By 

Landon Carter Gray, M.D., Professor of Diseases of the Mind and Nervous System 
in the New York Polyclinic. In one very handsome octavo volume of 681 pages, with 
168 illustrations. Cloth, $4.50; leather, $5.50. 

A book that will be welcomed by the many who 
desire a modern text-book on nervous diseases 
that is comprehensive and practical, and especial 



ly full in the details of the treatment of these 
affections that are so often matters of perplexity 
to the general practitioner. It will be found, on 
this account, to meet the wants of a large number 
perhaps better than would another equally meri 
torious text-book less full in this regard. Dr. Gray 
states in his preface, and it is evident to anyone 
perusing the work, that "especial care has been 
taken to make the therapeutical suggestions suf- 
ficiently detailed and precise to cover the varying 
stages, symptoms and complications of disease, as 
well as to follow the important indications afford- 
ed by differential diagnosis," and that "only that 
knowledge has been admitted to these pages 
which has stood the test of experience." Its style 
is clear and very readable, and the illustrations are 
numerous and excellent. A glossary of special 



terms is appended which will be found useful by 
the student. While it is intended as a text-book, 
not assuming any special knowledge on the part 
of its readers, the volume is full of valuable orig- 
inal matter that renders it a desirable addition to 
the library of the specialist in nervous and mental 
diseases.— American Jour, of Mental Sci. Feb., 1893. 

A highly successful effort to condense into a 
volume of reasonable size a practical knowledge 
of nervous and mental diseases. It is a book 
which the neurologist can consult with interest 
and advantage, and one which will be found par- 
ticularly useful to the student and general prac- 
titioner. The large space which throughout the 
work has been given to the discussion of sympto- 
matology and treatment will serve to make it 
popular, especially with busy workers. Dr. Gray's 
book will long hold its place as a standard treatise. 
— The Medical News, April 15, 1893. 



Ross on Diseases of the Nervous System. 

A Handbook on Diseases of the Nervous System. By James 
Ross, M. D., F. R. C. P., LL.D., Senior Assistant Physician to the Manchester Eoyal 
Infirmary. In one octavo vol. of 725 pages, with 184 illus. Cloth, $4.50 ; leather, $5.50. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner. — Edinburgh Medical Journal, Jan. 1887. 



Hamilton on Nervous Diseases —Second Edition. 

Nervous Diseases ; Their Description and Treatment. By Allen McLane 
Hamilton, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, 
Blackwell's Island, N. Y. Second edition, thoroughly revised and rewritten. In one 
octavo volume of 598 pages, with 72 illustrations. Cloth, $4.00. 



When the first edition of this good book appeared 
we gave it our emphatic endorsement, and the 
present edition enhances our appreciation of the 
book and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



characterized this book as the best of its kind in 
any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old. — 
Alienist and Neurologist, April, 1882. 



Savage on Insanity and Allied Neuroses. 

Insanity and Allied Neuroses, Practical and Clinical. By George 
H. Savage, M. D., Lecturer on Mental Diseases at Guy's Hospital, London. In one 
12mo. vol. of 551 pp., with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, p. 30. 

Klein's Histology —Fourth Edition. 

Elements of Histology. By E. Klein, M. D., F. B. S., Joint Lecturer on 
General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, 
London. Fourth edition. In one 12mo. volume of 376 pages, with 194 illus. Limp 
cloth, $1.75. See Students' Series of Manuals, page 30. 

The large number of editions through which 
Dr. Klein's little handbook of histology has run 
since its first appearance in 1883 is ample evidence 
that it is appreciated by the medical student and 
that it supplies a definite want. The clear and 



concise manner in which it is written, the 
absence of debatable matter, of conflicting views, 
added to the convenient size of the book and its 
moderate price, will account for its undoubted 
success. — Medical Chronicle, Feb., 1890. 



Schafer's Histology— Third Edition. 

The Essentials of Histology. By Edward A. Schafer, F. K. S., Jodrell 
Professor of Physiology in University College, London. New (third) edition. In one 
octavo volume of 311 pages, with 325 illustrations. Cloth, $3.00. 



BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. In one very 
handsome octavo volume. 

JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS. Second 



American Edition. In one handsome octavo 
volume of 340 pages. Cloth, $3.25. 
PEPPER'S SURGICAL PATHOLOGY. In one 
pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See 
Students'' Series of Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansorn Street, Philadelphia. 



Pathology, Histology, Bacteriology. 19 



Gihbes' Practical Pathology and Morbid Histology. 

Practical Pathology and Morbid Histology. By Heneage Gibbes, 
M. D., Professor of Pathology in the University of Michigan, Medical Department. In 
one very handsome 8vo. vol. of 314 pp., with 60 illus., mostly photographic. Cloth, $2.75. 

The work is throughout profusely illustrated with 
reproductions of micro-photographs. We may 



say that the practical histologist will gain mucl 
useful information from the book.— The London 



This is, in part, an expansion of the little work 
published by the author some years ago, and his 
acknowledged skill as a practical microscopist will 
give weight to his instructions. Indeed, m ful- 
ness of directions as to the modes of investigating I Lancet, January 23, 1892. 
morbid tissues the book leaves little to be desired. | 

Abbott's Bacteriology. 

The Principles of Bacteriology : a Practical Manual for Students and 
Physicians. By A. C. Abbott, M. D., First Assistant, Laboratory of Hygiene, University 
of Pennsylvania, Philadelphia. In one 12mo. vol. of 259 pp., with 32 illus. Cloth, $2.00. 

To a person desiring to learn the technique of ] judgment in the selection and arrangement of 
bacteriological work, we cannot recommend any ' 
work which will be more suitable than the one 
before us. The fault which can be found with 
most of the works we have met with on this sub- 
ject, is that they are too extended for the use of a 
student or practitioner beginning the subject and 
yet are not sufficiently large to allow of an ex- 
haustive treatment. Dr. Abbott has shown great 



his material. The student who follows it closely 
will be in a condition to carry forward the work 
for himself. Medical practitioners generally could 
read the work with profit, especially the chapters 
on sterilization and disinfection, and those on 
tuberculosis and diphtheria in the second part.— 
The Canadian Practitioner, Nov. 1, 1892. 



Senn's Surgical Bacteriology —Second Edition. 

Surgical Bacteriology. By Nicholas Senn, M. D., Ph. D., Professor of 
Surgery in Eush Medical College, Chicago. New (second) edition. In one handsome 
octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. 



The book is really a systematic collection in the 
most concise form of such results as are published 
in current medical literature by the ablest workers 
in this field of surgical progress ; and to these are 
added the author's own views and the results of 
his clinical experience and original investigations. 
The book is valuable to the student, but its chief 
value lies in the fact that such a compilation 



makes it possible for the busy practitioner, whose 
time for reading is limited and whose sources of 
information are often few, to become conversant 
with the most modern and advanced ideas in sur- 
gical pathology, which have "laid the foundation 
for the wonderful achievements of modern sur- 
gery." — Annals of Surgery, March, 1892. 



Green's Pathology and Morbid Anatomy —Seventh Edition. 

Pathology and Morbid Anatomy. By T. Henry Green, M. D., Lecturer 
on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 
Sixth American from the seventh and revised English edition. Octavo, 539 pages, with 
167 engravings. Cloth, $2.75. 



The Pathology and Morbid Anatomy of Dr. 
Green is too well known by members of the medi- 
cal profession to need any commendation. There 
is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work of the kind 
with which we are acquainted. The works of 
German authors upon pathology, which have been 



translated into English, are too abstruse for the 
physician. Dr. Green's work precisely meets his 
wishes. The cuts exhibit the appearances of 
pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is evidence that we have not spoken too 
much in its favor.— -Cincinnati Medical News, Oct. 
1889. 



Payne's General Pathology. 



A Manual of General Pathology. Designed as an Introduction to the 
Practice of Medicine. By Joseph F. Payne, M. D., F. R. C. P., Senior Assistant Physi- 
cian and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Octavo of 
524 pages, with 152 illustrations and a colored plate. Cloth, $3.50. 



Knowing, as a teacher and examiner, the exact 
needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 
tion of disease, and more especially to the etiologi- 



cal factors in those diseases now with reasonable 
certainty ascribed to pathogenetic microbes. In 
this department he has been very full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of research, is alone worth the price of the 
book, several times over, to every student of 
pathology. — St. Louis Med. and Surg. Jour., Jan. '89. 



Coats' Treatise on Pathology. 



A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Patholo- 
gist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 
pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 

manner, the changes from a normal condition 



Medical students as well as physicians, who 
desire a work for study or reference, that treats 
the subjects in the various departments in a very 
thorough manner, but without prolixity, will cer- 
tainly give this one the preference to any with 
which we are acquainted. It sets forth the most 
recent discoveries, exhibits, in an interesting 



effected in structures by disease, and points out 
the characteristics of various morbid agencies, 
so that they can be easily recognized. But, not 
limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 
conditions.— Cincinnati Medical News, Oct. 1883. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



20 



Surgery. 



Ashhurst's Surgery —New (6th) Edition. Just Ready. 

The Principles and Practice of Surgery. By John Ashhurst, Jr. 
M. D., Professor of Surgery and Clinical Surgery in the Univ. of Penna., Surgeon to the 
Penna. Hospital, Philadelphia. New (6th) edition, enlarged and thoroughly revised. 
Octavo, 1161 pages, 656 engravings and a colored plate. Cloth, $6.00 ; leather, $7.00. 



Ashhurst's Surgery maintains in its sixth edition 
the high standard of excellence which has always 
been its characteristic. The author has so thor- 
oughly revised his work that the most recent 
appliances and methods in surgery are mentioned. 
Dr. Nancrede has added an excellent chapter on 
Surgical Bacteriology, and the sections relating 
to surgical diseases of women and diseases of the 
eye and ear have been thoroughly gone over and 
brought to date by eminent men m these special- 
ties. This has added greatly to the value of the 
book. Dr. Ashhurst's well-known, comprehen- 
sive, and yet concise treatment of the various 
subjects is even more marked in this than in the 
previous editions. A great deal of new matter has 
been abided without making the volume unwieldy. 
Condensation and elimination have been most 
skilfully done where necessary. — The Cliicago 
Medical Recorder, January, 1894. 

This concise work treats in the most compact 



form compatible with clearness of the modern 
methods employed in the management of surgical 
affections. The principles upon which these 
directions are based are clearly stated, and defi- 
nite reasons given lor the course recommended. 
The popularity of this work is demonstrated by 
the fact that a sixth edition has become necessary, 
and the author has spared no pains to incorporate 
in it all the more recent discoveries and practical 
advances which have been made in surgical sci- 
ence. A new chapter has been introduced on 
Surgical Bacteriology. The series of illustrations 
has been enriched by the addition of a number of 
original cuts and of a colored plate illustrating 
bacteriological subjects. The work is thoroughly 
in touch with the times, and deals with each sub- 
ject in a manner characteristic of the author. 
Nothing is left unsaid which would add to the 
practical usefulness of t he book. — The International 
Magazine, December, 1893. 



Roberts' Modern Surgery. 



The Principles and Practice of Modern Surgery. For the use of Stu- 
dents and Practitioners of Medicine and Surgery. By John B. Roberts, M. D., Prof, of 
Anatomy and Surgery in the Philadelphia Polyclinic. Prof, of Surgery in the Woman's 
Medical College of Pennsylvania. Lecturer in Anatomy in the Univ. of Penna. Octavo, 
780 pages, 501 illustrations. Cloth, $4.50; leather, $5.50. 



This work is a very comprehensive manual upon 
general surgery, and will doubtless meet with a 
favorable reception by the profession. It, has a 
thoroughly practical character, the subjects are 
treated with rare judgment, its conclusions are in 
accord with those of the leading practitioners of 
the art, and its literature is fully up to all the ad- 



vanced doctrines and methods of practice of the 
present day. Its general arrangement follows 
this rule, and the author in his desire to be con- 
cise and practical is at times almost dogmatic, but 
this is entirely excusable considering the admira- 
ble manner in which he has thus increased the 
usefulness of his work. — Med. Rec, Jan. 17, 1891. 



Druitt's Modern Surgery —Twelfth Edition. 

Manual of Modern Surgery. By Eobert Druitt, M. B. C. S. Twelfth 
edition, thoroughly revised by Stanley Boyd, M. B., B. S., F. R. C. S. In one 8vo. 
volume of 965 pages, with 373 illustrations. Cloth. $4.00; leather, $5 00. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 



appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. — Cincinnati Medical 
News, September, 1887. 



Young's Orthopedic Surgery— In Press. 

A Manual of Orthopsedic Surgery, for Students and Practi- 
tioners. By James K. Young, M. D., Instructor in Orthopaedic Surgery, University of 
Pennsylvania, Philadelphia. In one octavo volume of about 400 pages, richly illustrated. 

The correction of deformities constitutes so large and important a department of 
surgery that it cannot be adequately dealt with except in a special treatise. The able 
author of this forthcoming work has provided a guide which in clearness of text and 
richness and beauty of illustration will leave nothing to be desired. The afflictions 
therein treated are unfortunately frequent in every community, and the work is therefore 
one which will be of the utmost value to the general practitioner, the surgeon and like- 
wise the orthopsedist. 

Sutton on Tumors, Innocent and Malignant.— Just Ready. 

Tumors, Innocent and Malignant. Their Clinical Features and Ap- 
propriate Treatment. By J. Bland Sutton, F. B. C. S., Assistant Surgeon to the Mid- 
dlesex Hospital, London. In one very handsome octavo volume of 526 pages, with 250 
engravings and 9 full page plates. Cloth, $4.50. 



BUTLIN ON DISEASES OP THE TONGUE. By 
Henry T. Butlin, F. R. C.S., Assistant Surgeon 
to St. Bartholomew's Hospital, London. In one 
12mo. volume of 456 pages, with 8 colored plates 
and 3 woodcuts. Cloth, $3.50. See Series of Clin- 
i<vrl Manuals page 30. 

GOULD'S ELEMENTS OF SURGICAL DIAG- 
NOSIS. By A. Pearce Gould, M S., M. B., 
F. R. C. S., Assistant Surgeon to Middlesex Hos- 
pital, London. In one pocket-size 12mo. volume 
of 589 pages. Cloth, $2.00. See Students' Series 
of Manuals, page 30. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. 

GANT'S STUDENT'S SURGERY. By Frederick 
James Gant, F. R. C. S. Square octavo, 848 pages, 
159 engravings. Cloth, $3.75. 

MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American edition. In one large 8vo. 
vol. of 682 pp.. with 364 illustrations. Cloth, $3.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh ed. Id one 
8vo. vol. of 638 pages, with 340 illus. Cloth, $3.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Surgery — (Continued). 



21 



Wharton's Minor Surgery and Bandaging — 2d Ed. Just Ready. 

Minor Surgery and Bandaging. By Henry E. Wharton, M. D., 
Demonstrator of Surgery in the University of Pennsylvania. In one 12mo. volume of 
529 pages, with 416 engravings, many being photographic. Cloth, $3.00. 

It is but little more than two years ago that we | specially commended, particularly those that re- 
published a review notice of Wharton's first late to bandaging, most of which have been taken 
edition. At that time, we remarked that the book from photographs of applied bandages in the 

" :al' ' " 



was one of the very best treatises on minor sur 
gery that had been published, that it ought to be 



several localities of the body. The author has 
thoroughly revised that portion of the work 



adopted as a text book on the subjects of which it | relating to the aseptic and antiseptic methods of 



treats, and that it contained more practical sur 

fery within its limits and boundaries than any 
ook of its kind we had ever seen. "What was 
true of the first edition may be, with propriety 



wound treatment, than which there is no more 
important subject in the whole domain of sur- 
gery. Much new matter has been added, which 
brings it abieast of the very latest knowledge on 



repeated and accentuated in regard to this second 1 he subjects of which it treats. — Buffalo Medical 
and revised edition. Its illustrations are to be j and Surgical Journal, January, 1894. 

Treves' Operative Surgery —Two Volumes. 

A Manual of Operative Surgery. By Frederick Treves, F. K. C. S., 
Surgeon and Lecturer on Anatomy at the London Hospital, in two octavo volumes 

Complete work, cloth, $9.00; leather, $11.00. 
not fail to be of the greatest use both to practical 
surgeons and to those general practitioners who, 
owing to their isolation or to other circumstances, 
are forced to do much of their own operative work. 
We feel called upon to recommend the book so 
strongly for the excellent judgment displayed in 
the arduous task of selecting from among the 
thousands of varying procedures those most 
worthy of description; for the way in which the 
still more difficult task of choosing among the 
best of those has been accomplished; and for the 
simple, clear, straightforward manner in which 
the information thus gathered from all surgical 
literature has been conveyed to the reader. — 
Annals of Surgery, March, 1892. 

Treves' Student's Handbook of Surgical Operations. In one 

square 12mo. volume of 508 pages, with 94 illustrations. Cloth, $2.50. 

A Manual of Surgery. In Treatises by Various Authors, edited by Fred- 
erick Treves, F. B. C. S. Ln three 12m<>. volumes, containing 1866 pages, with 213 
engravings. Price per set, cloth, $6.00. See Students' Series of Manuals, page 30. 



containing 1550 pages, with 422 engravings. 

Mr. Treves in this admirable manual of opera- 
tive surgery has in each instance practically 
assumed that operation has been decided upon 
and has then proceeded to give the various opera- 
tive methods which may be employed, with a 
criticism of their comparative value and a detailed 
and careful description of each particular stage 
of their performance. Especial attention has been 
paid to the preparatory treatment of the patient 
and to the details of the after treatment of the 
case, and this is one of the most distinctive among 
the many excellent features of the book. We have 
no hesitation in declaring it the best work on the 
subject in the English language, and indeed, in 
many respects, the best in any language. It can- 



We have here the opinions of thirty-three 
authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance. — Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



Treves on Intestinal Obstruction. In one 12mo. volume of 522 pages, 
with 60 illus. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 30. 

Erichsen's Science and Art of Surgery— Eighth Edition. 

The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, 
Diseases and Operations. By John E. Erichsen, F. B. S., F. B. C. S., Professor of Sur- 
gery in University College, London, etc. From the eighth and enlarged English edition. 
In two large 8vo. vols, of 2316 pp., with 984 engravings on wood. Cloth, $9; leather, $11. 



For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 
through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 



of the former edition has been dropped and no 
discovery, device or improvement which has 
marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
— Louisville Medical News, Feb. 14, 1885. 



Bryant's Practice of Surgery —Fourth Edition. 

The Practice of Surgery. By Thomas Bryant, F. B. C. S., Surgeon and 
Lecturer on Surgery at Gay's Hospital, London. Fourth American from the fourth and 
revised English edition, ln one large and very handsome imperial octavo volume of 1040 
pages, with 727 illustrations. Cloth, $6.50; leather, $7.50. 



The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 



place the work among the highest order of text- 
books for the medical student. Almost every 
topic in surgery is presented in such a form as to 
enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical .-Chicago Med. Jour, and Examiner, Apr. '86. 



HOLMES' SYSTEM OF SURGERY. THEORET- 
ICAL AND PRACTICAL. By Various Authors. 
Edited by Timothy Holmes, M. A. American edi- 
tion, revised and re-edited by John H. Packard, 



M. D. Three large octavo volumes, 3137 pages, 
979 illustrations on wood and 13 lithographic 
plates. Per set, cloth, 818.00; leather, $21.00. 
Subscription only. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia 



22 Surgery— (Continued), Fractures, Dislocations. 



Smith's Operative Surgery.— Revised Edition. 

The Principles and Practice of Operative Surgery. By Stephen 
Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. 
Second and thoroughly revised edition. In one very handsome octavo volume of 892 
pages, with 1005 illustrations. Cloth, $4.00 ; leather, $5.00. 

This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. The book is a compendium 



for the modern surgeon. The present edition is 
much enlarged, and the text has been thoroughly 
revised, so as to give the most improved methods 
in aseptic surgery, and the latest instruments 
known for operative work. It can be truly said that 
as a handbook for the student, a companion for the 



surgeon, and even as a book of reference for the 
physician not especially engaged in the practice 
of surgery, this volume will long hold a most 
conspicuous place, and seldom will its readers, no 
matter how unusual the subject, consult its pages 
in vain. Its compact form, excellent print, num- 
erous illustrations, and especially its decidedly 
practical character, all combine to commend it. — 
Boston Medical and Surgical Journal, May 10, 1888. 



Holmes' Treatise on Surgery— Fifth Edition. 

A Treatise on Surgery ; Its Principles and Practice. By Timothy 

Holmes, M. A., Surgeon and^ Lecturer on Surgery at St. George's Hospital, London. 
From the fifth English edition, edited by T. Pickering Pick, F. R. C. S. In one 
octavo volume of 997 pages, with 428 illustrations. Cloth, $6.00 ; leather, $7.00. 



To the younger members of the profession and 
to others not acquainted with the book and its 
merits, we take pleasure in recommending it as a 
surgery complete, thorough, well-written, fully 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



for the general practitioner, teaching those things 
that are necessary to be known for the successful 
prosecution of the surgeon's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient.— Pacific 
Medical Journal, July, 1889. 



Hamilton on Fractures and Dislocations— Eighth Edition. 

A Practical Treatise on Fractures and Dislocations. By Frank 
H. Hamilton, M. D., LL. D., Surgeon to Bellevue Hospital, New York. New (8th) edi- 
tion, revised and edited by Stephen Smith, M. D., Prof, of Clinical Surgery in Univ. of 
City of N. Y. In one octavo volume of 832 pp., with 507 illus. Cloth, $5.50 ; leather, $6.50. 

Its numerous editions are convincing proof if any 
is needed, of its value aud popularity. It is pre- 
eminently the authority on fractures and disloca- 
tions, and universally quoted as such. In the new 
edition it has lost none of its former worth. The 



additions it has received by its recent revision make 
it a work thoroughly in accordance with modern 
practice, theoretically, mechanically, aseptically. 
The task of writing a complete treatise on a sub- 



ject of such magnitude is no easy one. Dr. Smith 
has aimed to make the present volume a correct 
exponent of our knowledge of this department 
of surgery. The more one reads the more 
one is impressed with its completeness. The work 
has been accomplished, and has been done clearly, 
concisely, excellently well. — Boston Medical and 
Surgical Journal, May 26, 1892. 



Stiinson's Operative Surgery— Second Edition. 

A Manual of Operative Surgery. By Lewis A. Stimson, B. A., M. D., 
Professor of Clinical Surgery in the University of the City of New York. Second edi- 
tion. In one royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 



The author knows the difficult art of condensa- 
tion. Thus the manual serves as a work of 
reference, and at the same time as a handy 
guide. It teaches what it professes, the steps 
of operations. In this edition Dr. Stimson has 
sought to indicate the changes that have been 
effected in operative methods and procedures by 



the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation. — British Medical Journal, Jan. 22, 1887. 



Stimson on Fractures and Dislocations. 

A Treatise on Fractures and Dislocations. By Lewis A. Stimson, 
M. D. In two handsome octavo volumes. Vol. I., Fractures, 582 pages, 360 illustra- 
tions. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, 
cloth, $5.50 ; leather, $7.50. Either volume separately, cloth, $3.00 ; leather, $4.00. 



The appearance of the second volume marks the 
completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. This volume 



exhibits the surgery of Dislocations as it is taught 
and practised by the most eminent surgeons of the 
present time. Containing the results of such ex- 
tended researches it must for a long time be re- 
garded as an authority on all subjects pertaining 
to dislocations. Every practitioner of surgery will 
feel it incumbent on him to have it for constant 
reference. — Cincinnati Medical News, May, 1888. 



Pick on Fractures and Dislocations. 

Fractures and Dislocations. By T. Pickering Pick, F. K. C. S., Sur- 
geon to and Lecturer on Surgery at St. George's Hospital, London. In one 12mo. vol. 
of 530 pp., with 93 illus. Limp cloth, $2.00. See Series of Clinical Manuals, page 30. 

Marsh on the Joints. 

Diseases of the Joints. By Howard Marsh, F. E. C. S., Senior Assistant 
Surgeon to St. Bartholomew's Hospital, London. In one 12mo. volume of 468 pages, with 
64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Ophthalmology. 



23 



Norris & Oliver's Ophthalmology.— Just Ready. 

A Text-Book of Ophthalmology- By William F. Norris, M. D., 
Professor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, 
M. D., Surgeon to Wills' Eye Hospital, Philadelphia. In one very handsome octavo 
vol. of 641 pages, with 357 engravings and 5 colored plates. Cloth, $5 ; leather, $6. 

This is the first text-book of diseases of the eye, 
written by American authors for American col- 
leges and students. Every method of ocular pre- 
cision that can be of any clinical advantage to the 
every-day student and the scientific observer is 
offered to the reader, Rules and procedures for 
the ordinary methods of examination of the ex- 
ternal appearances of the eye, for ophthalmoscopy, 
and for the application of the fundus- reflex tests, 
are made so plain and so evident, even to the 
most careless reader, that any student can easily 
understand and employ them. It is succinct in 
recital, practical in its teachings, judicious in the 
selection of material and conservative, yet radical 
when necessary. In treatment it can be accepted 
as from the voice and the pen of a respected and 



recognized authority. The illustrations, many of 
which are original, far outnumber those of its 
contemporaries, whilst the high grade and un- 
biased opinions of the teachings serve to give it a 
rank superior to any would-be competitor. Won- 
derfully cheap in price, beautifully printed and 
exquisitely illustrated, the mechanical make-up 
of the book is all that can be desired. After most 
conscientious and pair staking perusal of the 
work, we unreservedly endorse it as the best, the 
safest and the most comprehensive volume upon 
the subject that has ever been offered to the 
American medical public. We sincerely hope 
that it may find its way into the list of text-books 
of every English-speaking college of medicine. — 
Annals of Ophthalmology and Otology, Oct. 1893. 



Berry on the Eye —New Edition. Just Ready. 

Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. 
By George A. Berry, ftf. B., F. E. C. S., Ed., Ophthalmic Surgeon, Edinburgh Koyal 
Infirmary. New (second) edition, [n one octavo volume of 750 pages, with 197 illustra- 
tions, mostly lithographic. Cloth, $8.00, 



This is by far the best work upon its theme in 
the English language that we have seen, for the 
diction is pure and clear, and besides, the beauti- 
ful illustrations of normal and diseased conditions 
make it a valuable addition to the library of all 
practitioners, general as well as special. We have 
never seen more real delineation of disease, the 
coloring is perfect, and each illustration is an 



"object-lesson." We cannot but reiterate what we 
said at the beginning, that we have had great pleas- 
ure in the perusal of this work, and great profit, and 
that we consider it the best on the subject in the 
English language to-day, not only for its diction 
but for its instructive illustrations. — The American 
Journal of the Medical Sciences, August, 1893. 



Jaler's Ophthalmic Science and Practice. — NEW <2d> ^u™ms'ady. 

A Handbook of Ophthalmic Science and Practice. By Henry E. 
Juler, F. B. C. S., Senior Assistant Surgeon, Boyal Westminster Ophthalmic Hospital; 
Late Clinical Assistant, Moorfields, London. New (2d) edition. Handsome 870. volume 
of 561 pages, with 201 woodcuts, 17 colored plates, selections from Test-types of Jaeger 
and Snellen, and Holmgren's Color-blindness Test. Cloth, $5.50 ; leather, $6.50. 



The continuous approval manifested towards 
this work testifies to the success with which the 
author has produced concise descriptions and 
typical illustrations of all the important affections 
of the eye. The volume is particularly rich in 



matter of practical value. The sections devoted to 
treatment are singularly full, and at the same time 
concise, and couched in language that cannot fail 
to be understood.— The Medical Age, Nov. 10, 1893. 



Nettleship on the Eye —Fifth Edition. 

Diseases of the Eye. By Edward Nettleship, F. E. C. S., Ophthalmic 
Surgeon at St. Thomas' Hospital, London. Surgeon to the Boyal London (Moorfields) 
Ophthalmic Hospital. Fourth American from the fifth English edition, thor- 
oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College 
Philadelphia. In one 12mo. volume of 500 pages, with 164 illustrations, selections from 
Snellen's test-types and formula?, and a colored plate. Cloth, $2.00. 

' knowledge to be present which seems to be as- 



This is a well-known and a valuable work. It 
was primarily intended for the use of students, 
and supplies their needs admirably, but it is as 
useful for the practitioner, or indeed more so. It 
does not presuppose the large amount of recondite 



sumed in some of our larger works, is not tedious 
from over-conciseness, and yet covers the more 
important parts of clinical ophthalmology. — New 
York Medical Journal, December 13, 1890. 



Carter & Frost's Ophthalmic Surgery. 

Ophthalmic Surgery. By B. Brudenell Carter, F.B. C. S., Lecturer on 
Ophthalmic Surgery at St. George's Hospital, London, and W. Adams Frost, F. B. C. S., 
Joint Lecturer on Ophthalmic Surgery at St. George's Hospital, London. In one 12mo. 
volume of 559 pages, with 91 woodcuts, color-blindness test, test-types and dots and appen- 
dix of formulae. Cloth, $2.25. See Series of Clinical Manuals, page 30. 

THOMPSON ON THE URINARY ORGANS. 
Lectures on Diseases of the Urinary Organs. 
By Sir Henry Thompson, Professor of Clinical 
Surgery in University College Hospital, London. 
Second American from the third English edition. 
Octavo, 203 pages, 25 illustrations. Cloth, $2 25. 
THOMPSON ON THE PATHOLOGY AND 
TREATMENT OF STRICTURE OF THE 

URETHRA AND URINARY FISTULA. 

From the third English edition. In one octavo 

volume of 359 pages, with 47 engravings and 3 

plates. Cloth, $3.50. 



BASHAM ON RENAL DISEASES: A Clinical 
Guide to their Diagnosis and Treatment. 12mo. 
304* pages, with 21 illustrations. Cloth, $2.00. 

WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 

LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. In one octavo volume of 404 pages, with 
92 illustrations. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



24 Otology, Urinary & Renal Dis., Dentistry. 
Politzer on Diseases of the Ear— New Edition. Just Ready. 

A Text-Bpok of Diseases of the Ear and Adjacent Organs. 

By Dr. Adam Politzer, Imperial-Boyal Professor of Aural Therapeutics in the Univer- 
sity of Vienna, Chief of the Imperial -Koyal University Clinic for Diseases of the Ear in 
the General Hospital, Vienna. Translated into English from the third aid revised 
German edition, by Oscar Dodd, M. D., Clinical Instructor in Diseases of the Eye and 
Ear, College of Physicians and Surgeons, Chicago. Edited by Sir William Dalby, 
F. E. C. S., M. B., Consulting Aural Surgeon to St. George's Hospital, London. In one 
large octavo volume of 748 pages, with 330 illustrations. Cloth, §5.50. 

Field's Manual of Diseases of the Ear.— Just Ready. 

A Manual of Diseases of the Ear. By George P. Field M. E. C. S., 
Aural Surgeon and Lecturer on Aural Surgery in St Mary's Hospital Medical School, 
London. In onf octavo o' 891 pp., with 73 engravings and 21 colored plates. Cloth, $3.75. 



The author's views are so plainly and forcibly 
expressed that the student and general practi- 
tioner of medicine cannot afford to be without 
their teaching and careful guidance if they would 
do the justice to their patients that the present 
advanced state of otology demands. Within the 



covers of this book will be found information suf- 
ficient to supply the needs of the student and 
practitioner of general medicine in practical mat- 
ters per caining to diseases of the ear.— The Thera- 
peutic Gazette, January 15, 1994. 



Burnett on the Ear— Second Edition. 

The Sar, Its Anatomy, Physiology and Diseases. A Practical 
Treatise tor the use of Medical Students and Practitioners. By Chahles H. Burnett, 
A.M., M. D., Professor of Otology in the Philadelphia Polyclinic; President of the 
American Otological Society. Second edition. In one handsome octavo volume of 580 
pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

Roberts on Urinary and Renal Diseases— Fourth Edition. 

A Practical Treatise on Urinary and Renal Diseases, including 
Urinary Deposits. By Sir William Eoberts, M. D., Lecturer on Medicine in the 
Manchester School of Medicine, etc. Fourth American from the fourth London edi- 
tion. In one handsome octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

It maybe said to be the best book in print on the sis, prognosis and treatment of urinary diseases, 
subject of which it treats. — The American Journal and possesses a completeness not found else- 
of the Medical Sciences, Jan. 1886. where in our language in its account of the differ- 

It is an unrivalled exposition of everything ent affections.- Manchester Med. Chron., July, '85. 
which relates directly or indirectly to the diagno- 



Purdy on Bright's Disease and Allied Affections. 

Bright's Disease and Allied Affections of the Kidneys. By 

Charles W. Purdy, M. D., Professor of Genito-Urinary and Renal Diseases in the Chi- 
cago Polyclinic. In one octavo vol. of 288 pages, with illustrations. Cloth, $2.00. 

The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 
1886. 



The American System of Dentistry. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M.D., 

D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. For sale by subscription only. 



As an encyclopaedia of Dentistry it has no su- 
perior. It should form a part of every dentist's 
library, as the information it contains is of the 
greatest value to all engaged in the practice of 
dentistry.— American Jour. Dent Sci., Sept. 1886. 

A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it — they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while the profession at large 
will receive incalculable benefit from it. — Odonto- 
graphy Journal, Jan. 1887. 



Coleman's Dental Surgery— American Edition. 

A Manual of Dental Surgery and Pathology. By Alfred Coleman 
L. E. C. P., F. R. C. S., Exam. L. D. S.,_ Lecturer on Dental Surgery at St. Bartholomew's" 
Hospital, London. Thoroughly revised and adapted to the use of American Students, by 
by Thomas C. Stellwagen, M. A., M. T)., D. D. S., Prof, of Physiology in the Philadel- 
phia Dental College. Octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. 



MORRIS ON SURGICAL DISEASES OF THE 
KIDNEY. By Henry Morris, F. R. C. S., Surgeon 
to Middlesex Hospital, London. 12mo., 554 pp., 



with 40 woodcuts, and G colored plates. Limp 
cloth, $2.25. , See Series of Clinical Manuals, p. 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Impotence, Sterility, Venereal, Skin. 



25 



Gross on Impotence, Sterility, etc.— Fourth Edition. 

A Practical Treatise on 'Impotence, Sterility, and Allied Dis- 
orders of the Male Sexual Organs. By Samuel W. Gross, A. M., M. D., 
LL. D., Professor of the Principles . of Surgery and of Clinical Surgery in the Jefferson 
Medical College of Philadelphia. Fourth edition, thoroughly revised by F. R. Sturgis, 
M. D., Prof, of Diseases of the Genito-Urinary Organs and of Venereal Diseases, 
N. Y. Post Grad. Med. School. In one 8vo. vol. of 165 pages, with 18 illus. Cloth, $1.50. 



Three editions of Professor Gross' valuable book 
have been exhausted, and still the demand is 
unsupplied. Dr. Sturgis has revised aud added 
to the previous editions, and the new one appears 
more complete and more valuable than before. 
Four important and generally misunderstood sub- 
jects are treated — impotence, sterility, spermator- 



rhoea, and prostatorrhcea. The book is a practical 
one and in addition to the scientific and very in- 
teresting discussions on etiology, symptoms, etc., 
there are lines of treatment laid down that any 
practitioner can follow and which have met with 
success in the hands of author and editor. — Medi- 
cal Record, Feb. 25, 1891. 



Taylor on Venereal Diseases —Sixth Edition. Preparing. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. By Eobert W. Taylor, A. M., M. D., 
Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons, 
New York. Being the sixth edition of JBumstead and Taylor, rewritten by Dr. Taylor. 
Large 8vo. volume, about 900 pages, with about 150 engravings, as well as numerous 
chromo-lithographs. In active preparation. A notice of the previous edition is appended. 

It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 



upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes. — Am. Jour, of the Med. Sciences, Jan. 1884. 



Culver & Hayden's Manual of Venereal Diseases. 

A Manual of Venereal Diseases. By Everett M. Culver, M. D., 
Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James 
K. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur- 
geons, New York. In one 12mo. volume of 289 pages, with 33 illus. Cloth, $1.75. 



This book is a practical treatise, presenting in a 
condensed form the essential features of our pres- 
ent knowledge of the three venereal diseases, 
syphilis, chancroid and gonorrhea. We have ex- 
amined this work carefully and have come to the 
conclusion that it is the most concise, direct and 
able treatise that has appeared on the subject of 



venereal diseases for the general practitioner to 
adopt as a guide. The general practitioner needs 
a few simple, concise and clearly presented laws, 
in the execution of which he cannot fail either to 
cure or prevent the ravages of the maladies in 
question and their direful results. — Buffalo Medical 
and Surgical Journal, May, 1892. 



Cornil on Syphilis. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. By V. 

Cornil, Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hos- 
pital. Specially revised by the Author, and translated with notes and additions by J. 
Henry C. Simes, M. D., Demonstrator of Pathological Histology in the Univ. of Pa., 
and J. William White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one 
handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 



The anatomy, the histology, the pathology and 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
instructive form, and no one will rise from its 



perusal without the feeling that his grasp of the 
wide and important subject on which it treats is 
a stronger and surer one. — The London Practi- 
tioner, Jan. 1882. 



Hutchinson on Syphilis. 

Syphilis. By Jonathan Hutchinson, F. K. S., F. E. C. S., Consulting Sur- 
geon to the London Hospital. In one 12mo. volume of 542 pages, with 8 chromo- 
lithographs. Cloth, $2.25. See Series of Clinical Manuals, page 30. 

Those who have seen most of the disease and 1 facts and suggestions which abound in these 
those who have felt the real difficulties of diagno- pages.— London Medical Record, Nov. 12, 1887. 
sis and treatment will most highly appreciate the | 

Gross on the Urinary Organs. 

A Practical Treatise on the Diseases, Injuries and Malforma- 
tions of the Urinary Bladder, the Prostate Gland and the Urethra. 

By Samuel D. Gross, M. D., LL. D., D. C. L. etc. Third edition, thoroughly revised 
by Samuel W. Gross, M. D. In one octavo vol. of 574 pp., with 170 illus. Cloth, $4.50. 



FOX'S EPITOME OF SKIN DISEASES. WITH 
FORMULAE. Third edition, revised and en- 
larged. In one 12mo. vol. of 238 pp. Cloth, $ 1.25. 

HILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, 
with plates. Cloth, $2.25. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. 



LEE'S LECTURES ON SYPHILIS AND SOME 
FORMS OF LOCAL DISEASE AFFECTING 
THE ORGANS OF GENERATION. In one 
8vo. volume of 246 pages. Cloth. $2.25. 
WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE AND DISEASES OF THE SKIN. 
In one handsome small octavo volume of 535 
Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



26 



Venereal and Skin Diseases. 



Hyde on the Skin.— New (3d) Edition. Just Ready. 

A Practical Treatise on Diseases of the Skin. For the use of Students 
and Practitioners. By J. Nevins Hyde, A. M., M. D., Professor of Dermatology and Ven- 
ereal Diseases in Rush Medical College, Chicago. Third edition. In one octavo volume 



of 802 pages, with 9 colored plates and 108 
After careful review of this work we remain 
deeply impressed with its excellence. With the 
improvements of the present edition it embraces 
a very wide range of subjects, giving descriptions 
of all the familiar diseases of the skin and of a 
great number of rare disorders, and in all points 
the work is brought up to date. As a handbook of 
dermatology for the student, the general prac- 
titioner, or the specialist, the work will at once 
take its place among the very best which have yet 



engravings. Cloth, $5.00; leather, $6.00. 
been put forth descriptive of skin diseases as they 
are seen in America. In discussing methods of 
treatment the author avoids skilfully the two 
extremes of over-wordy confusion and over-bare 
conciseness, and gives a plain yet brief account 
of his own methods and those of the best special- 
ists in dealing with each disease. The colored 
illustrations are excellent. — Maryland Medical 
Journal, November 4, 1893. 



Taylor's Clinical Atlas of Venereal and Skin Diseases. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diag- 
nosis, Prognosis and Treatment. By Eobert W. Taylor, A. M., M. D., Clinical Pro- 
fessor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York ; 
In eight large folio parts, and comprising 58 beautifully colored plates with 213 figures, 
and 431 pages of text with 85 engravings. Price per part, $2.50. Bound in one volume, 
half Eussia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 

It would be hard to use words which would per- 
spicuously enough convey to the reader the great 
value of this Clinical Atlas. This Atlas is more 
complete even than an ordinary course of clinical 
lectures, for in no one college or hospital course 
is it at all probable that all of the diseases herein 
represented would be seen. It is also more ser- 
viceable to the majority of students than attend- 
ance upon clinical lectures, for most of the 
students who sit on remote seats in the lecture 
hall cannot see the subject as well as the office 



student can examine these true-to-life chromo-lith- 
ographs. Comparing the text to a lecturer, it is 
more satisfactory in exactness and fullness than 
he would be likely to be in lecturing over a single 
case. Indeed, this Atlas is invaluable to the gen- 
eral practitioner, for it enables the eye of the 
physician to make diagnosis of a given case of 
skin manifestation by comparing the case with 
the picture in the Atlas, where will be found also 
the text of diagnosis, pathology, and full sections 
on treatment. — Virginia Medical Monthly, Dec. 1889. 



Jackson's Ready-Reference Handbook of Skin Diseases. 

The Ready-Reference Handbook of Diseases of the Skin. By 

George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College 
of the New York Infirmary. In one 12mo. volume of 544 pages, with 50 illustrations 
and a colored plate. Cloth, $2.75 



Intended to serve as a reference book for the 
general practitioner, "no attempt has been made 
to discuss debatable questions," and "hence pa- 
thology and etiology do not receive as full consid- 
eration as symptomatology, diagnosis and treat- 
ment." The alphabetical arrangement of diseases, 
so universal now in books of this class, has been 
followed by Dr. Jackson. After a short and con- 
densed account of the anatomy and physiology of 



the skin, the author presents a few notes of com- 
mon and practical importance on diagnosis and 
therapeutics, which are followed by his well- 
known and graphic dermatological "Don'ts." 
Part II. treats in alphabetical order of the dis- 
eases of the skin and their management. This 
book seems to us the best of its class that has 
yet appeared. — Boston Medical and Surgical Jour- 
nal, May 18, 1893. 



Pye-Smith on Diseases of the Skin.— Just Ready. 

A Handbook of Diseases of the Skin. By P. H. Pye-Smith, M. D., 
F. E. S., Physician to Guy's Hospital, London. In one octavo volume of 407 pages, 
with 26 illustrations, 18 of which are colored. • Cloth, $2.00. 
It is a plain, practical treatise on dermatology, advances made in this department of medicine 



written lor the student and general practitioner 
by a general practitioner of broad experience in 
the special subject of which he writes. He simpli- 
fies the nomenclature, and succeeds in removing 
much of the difficulty. After reviewing the recent 



he pays a merited compliment to the "important 
contributions made by the newest school of 
dermatology, that of America."— Pittsburg Medical 
Review, June, 1893. 



Hardaway's Manual of Skin Diseases. 

Manual of Skin Diseases. With Special Keferenceto diagnosis and Treat- 
ment. For the use of Students and General Practitioners. By W. A. Hardaway, M. D., 
Professor of Skin Diseases in the Missouri Medical College. 12mo., 440 pp. Cloth, $3.00. 

Dr. Hardaway's large experience as a teacher I embraces all essential points connected with the 
and writer has admirably fitted him for the dim- ] diagnosis and treatment of diseases of the skin, 
cult task of preparing a book which, while sum- I and we have no hesitation in commending it as 
ciently elementally for the student is yet suffi- t the best manual that has yet appeared in this 
ciently thorough and comprehensive to serve as a department of medicine.— Journal of Cutaneous 
book of reference for the genera l practitioner. It | and Genito- Urinar y Diseases. 

Jamieson on Diseases of the Skin.— Third Edition. 

Diseases of the Skin. A Manual for Students and Practitioners. By 
W. Allan Jamieson, M. D., Lecturer on Diseases of the Skin, School of Medicine, Edin- 
burgh. Third edition, revised and enlarged. In one octavo volume of 656 pages, with 
woodcut and 9 double-page chromo-lithographic illustrations. Cloth, $6.00. 

The scope of the work is essentially clinical, lit- general practitioner will find the book of great 



scope of the work is essentially 
tie reference being made to pathology or disputed 
theories. Almost every subject is followed by 
illustrative cases. The pages are filled with inter- 
est to all those occupied with skin diseases. The 



value in'matters of diagnosis and treatment. The 
latter is quite up to date, and the formulae have 
been selected with care.— Medical Record, April 9, 
1892. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Diseases of Women. 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work now ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 



These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor pre- 
sents a monograph upon his special topic, so that 
everything in the way of history, theory, methods, 
and results is presented to our fullest need. As a 
work of general reference, it will be found remarka- 
bly full and instructive in every direction of 
inquiry. — The Obstetric Gazette, September, 1889. 

One is at a loss to know what to say of this vol- 
ume, for fear that just and merited praise may be 
mistaken for flattery. The papers of Drs. Engel- 
mann, Martin, Hirst, Jaggard and Reeve are incom- 
parably beyond anything that can be found in 
obstetrical works. — Journal of the American Medical 
Association, Sept. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement: — "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 



United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
" System of Gynecology by American Authors." 
It, like the other, has been written exclusively 
by American physicians who are acquainted with 
all the characteristics of American people, who are 
well informed in regard to the peculiarities of 
American women, their manners, customs, modes 
of living, etc. As every practising physician is 
called upon to treat diseases of females, and as 
they constitute a class to which the family phy- 
sician must give attention, and cannot pass over 
to a specialist, we do not know of a work in any 
department of medicine that we should so strongly 
recommend medical men generally purchasing. — 
Cincinnati Med. News, July, 1887. 



Emmet's Gynaecology —Third Edition. 

The Principles and Practice of Gynecology ; For the use of Students 
and Practitioners of Medicine. By Thomas Addis Emmet, M. D., LL. D., Surgeon to 
the Woman's Hospital, New York, etc. Third edition, thoroughly revised. In one 
large and very handsome 8vo. vol. of 880 pp., with 150 illus. Cloth, $5 ; leather, $6. 

We are in doubt whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 



Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 



the privilege thus offered them of perusing the 
views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gynae- 
cological science and art. — British Medical Jour- 
nal, May 16, 1885. 



Tail's Diseases of Women and Abdominal Surgery. 

Diseases of Women and Abdominal Surgery. By Lawson Tait, 
F. E. C. S., Professor of Gynaecology in Queen's College, Birmingham, late President of 
the British Gynecological Society, Fellow American Gynaecological Society. In two 
octavo vols. Vol. I., 554 pp., 62 engravings and 3 plates. Cloth, $3. Vol. II., preparing. 

The plan of the work does not indicate the regu- Much of the text is abundantly illustrated with, 
lar system of a text- book, and yet nearly every- 
thing of disease pertaining to the various organs 
receives a fair consideration. *The description of 
diseased conditions is exceedingly clear, and the 
treatment, medical or surgical, is very satisfactory. 



cases, which add value in showing the results of 
the suggested plans of treatment. We feel con- 
fident that few gynecologists of the country will 
fail to place the work in their libraries. — The 
Obstetric Gazette, March, 1890. 



Edis on Diseases of Women. 

_ The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. By Arthur W. 
Edis, M. D., Lond., F. E. C. P., M. E. C. S., Assistant Obstetric Physician to Middlesex 
Hospital, late Physician to British Lying-in-Hospital. In one handsome octavo volume 
of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 

among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too, 
will find many useful hints in its pages. — Boston 
Med. and Surg. Journ., March 2, 1882. 



The special qualities which are conspicuous 
are thoroughness in covering the whole ground, 
clearness of description and conciseness of state- 
ment. Another marked feature of the book is 
the attention paid to the details of many minor 
surgical operations and procedures, as, for 
instance, the use of tents, application of leeches, 
and use of hot water injections. These are 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Including Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $4.50. 



WEST'S LECTURES ON THE DISEASES OF 
WOMEN. Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. 
Cloth, $3.75; leather, $4.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



28 



Diseases of Women — (Continued). 



Thomas & Munde on Diseases of Women— Sixth Edition. 

A Practical Treatise on the Diseases of Women. By T. Gaillard 
Thomas, M. D., LL. D., Emeritus Professor of Diseases of Women in the College of 
Physicians and Surgeons, New York, and Paul F. Munde, M.D., Professor of Gynecol- 
ogy in the New York Polyclinic. New (sixth) edition, thoroughly revised and rewritten 
by Dr. Munde. In one large and handsome octavo volume of 824 pages, with 347 
illustrations, of which 201 are new. Cloth, $5.00 ; leather, $6.00. 



The profession has sadly felt the want of a text- 
book on diseases of women, which should be com- 
prehensive and at the same time not diffuse, 
systematically arranged so as to be easily grasped 
by the student of limited experience, and which 
should embrace the wonderful advances which 
have been made within the last two decades. 
Thomas' work fulfilled these conditions, and the 
announcement that a new edition was about to be 
issued, revised by so competent a writer as Dr. 
Munde, was hailed with delight. Dr. Munde 
brings to his work a most practical knowledge of 
the subjects of which he treats and an exceptional 



acquaintance with the world's literature of this 
important branch of medicine. The result is 
what is, perhaps, on the whole, the best practical 
treatise on the subject in the English language. 
It is, as we have said, the best text-book we know, 
and will be of especial value to the general practi- 
tioner as well as to the specialist. The illustra- 
tions are very satisfactory. Many of them are 
new a ad are particularly clear and attractive. 
The book will undoubtedly meet with a favorable 
reception from the profession. — Boston Medical 
and Surgical Journal, January 14, 1892. 



Sutton on the Ovaries and Fallopian Tubes. 

Surgical Diseases of the Ovaries and Fallopian Tubes, including 
Tubal Pregnancy. By J. Bland Sutton, F. E. C. S., Assistant Surgeon to the 
Middlesex Hospital, London. In one crown octavo volume of 544 pages, with 119 
engravings and 5 colored plates. Cloth, $3.00. 

This is not a book to be read and then shelved ; needs just such a book. It will be of immense 
it is one to be studied. It is not based upon service to him in the study of pelvic diseases, and 
hypotheses but upon facts. It makes pathology will assuredly open his eyes to the progress made 
practical, and inculcates a practice based upon by conscientious, painstaking workers like Dr. 
pathology. It is succinct, yet thorough; practi- Sutton in the field of pathology and differential 
cal, yet scientific; conservative, yet bold. It is diagnosis.— International Medical Magazine, Sep- 
probably on the table of all gynecologists; but it tember, 1892. 
is not for them alone ; the general practitioner | 



Davenport's Non-Surgical Gynaecology— Second Edition. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. 

Designed especially for the Use of Students and General Practitioners. By Francis 
H. Davenport, M. D., Assistant in Gynaecology in the Medical Department of Harvard 
University, Boston. New (second) edition. In one handsome 12mo. volume of 314 
pages, with 107 illustrations. Cloth, $1.75. 



Many valuable volumes already exist on the 
surgical aspects of gynecology, but scant attention 
has been paid in recent years to the non-surgical 
treatment of women's diseases. The present 
volume, dealing with nothing which has not stood 



the actual test of experience, and being concisely 
and clearly written, conveys a great amount of in- 
formation in a convenient space.— Annals of Gynae- 
cology and Pcediatry, June, 1893. 



May's Manual of Diseases of Women.— Second Edition. 

A Manual of theDiseases of Women. Being a concise and systematic 
exposition of the theory and practice of gynecology. By Charles H. May, M. D., 
late House Surgeon to Mount Sinai Hospital, New York. Second edition, edited by 
L. S. Rau, M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. 
volume of 360 pages, with 31 illustrations Cloth, $1.75. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception, it is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily.— The Physician and 
Surgeon, June, 1890. 



Duncan on Diseases of Women. 

Clinical Lectures on the Diseases of "Women ; Delivered in Saint 
Bartholomew's Hospital. By J. Matthews Duncan, M. D., LL. D, F. E. S. E., etc. 
In one octavo volume of 175 pages. Cloth, $1.50. 

rule, adequately handled in the text-books ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that they deserve to be 
widely read.— N. Y. Medical Journal, March, 1880. 



They are in every way worthy of their author ; 
Indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 



American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Obstetrics. 



29 



Playfair's Midwifery— New (8th) Edition. Just Ready. 

A Treatise on the Science and Practice of Midwifery. By W. S. 

Playfair, M. D., F. E. C. P., Professor of Obstetric Medicine in King's College, Lon- 
don, Examiner in Midwifery in the Universities of Cambridge and London, and to the 
Koyal College of Physicians. Sixth American, from the eighth English edition. Edited, 
with additions, by Kobert P. Harris, M. D. In one handsome octavo volume of 697 
pages, with 217 engravings and 5 plates. Cloth, $4.00 ; leather, $5.00. 



The demand for eight English and six American 
editions of this standard work in seventeen years 
testifies to the success with which the author has 
executed his original purpose. His object " has 
been to place in the hands of his readers an epit- 
ome of the science and practice of midwifery 
which embodies all recent advances." He has 
endeavored to dwell especially on the practical 
part of the subject, so as to make the work a use- 
ful guide in this most anxious and responsible 
branch of the profession." The present issue is 
the result of a thorough revision of its predecessor 
at the hands of the author. It has likewise re- 
ceived the benefit of careful revision by Dr. Robert 
P. Harris, of Philadelphia, whose annotations in 
this and in previous editions have covered the 



points wherein American practice differs from 
that of English obstetricians The work will con- 
tinue to be a favorite text-book for the student 
and a trustworthy guide for the practitioner.— 
Memphis Medical Monthly, December, 1893. 

In the method of treating its theme, that is in 
clearness, perspicuity, in a smooth-flowing and 
yet terse literary style, notwithstanding the great 
number of new claimants in the field, this work 
still stands without a superior. The teachings on 
the various forms of anomalous and difficult labors 
are clear, full and explicit, and these practical 
matters bear the full stamp of the author's high 
authority. A book that already has the praise of 
the civilized world.— The American Practitioner 
and News, December 16, 1893. 



Parvin's Science and Art of Obstetrics— Second Edition. 

The Science and Art of Obstetrics. By Theophilus Parvin, M. D., 
LL. D., Professor of Obstetrics and the Diseases of Women and Children in Jefferson 
Medical College, Philadelphia. Second edition. In one handsome 8vo. volume of 701 
pages, with 239 engravings and a colored plate. Cloth, $4.25 ; leather, $5.25. 

The second edition of this work is fully up to the 
present state of advancement of the obstetric art. 
The author has succeeded exceedingly well in 
incorporating new matter without apparently in- 
creasing the size of his work or interfering with 
the smoothness and grace of its literary construc- 
tion. He is very felicitous in his descriptions of 
conditions, and proves himself in this respect a 



scholar and a master. Rarely in the range of 
obstetric literature can be found a work which is 
so comprehensive and yet compact and practical. 
In such respect it is essentially a text book of the 
first merit. The treatment of the subjects gives a 
real value to the work — the individualities of a 
practical teacher, a skilful obstetrician, a close 
thinker and a ripe scholar.— ikfeci. Rec, Jan. 17, '9t 



King's Manual of Obstetrics —Fifth Edition. 

A Manual of Obstetrics. By A. F. A. King, M. D., Professor of Obstetrics 
and Diseases of Women in the Medical Department of the Columbian University, Wash- 
ington, D. C, and in the University of Vermont, etc. New (fifth) edition. In one 12mo. 
volume of 446 pages, with 150 illustrations. Cloth, $2.50. 

So comprehensive a treatise could not be brought 
within the limits of a book of this size were not 



two things especially true. First, Dr. King is a 
teacher of many years' experience, and knows 
just how to present his subjects in a manner for 
them to be best received; and, secondly, he can 
put his ideas in a clear and concise form. In 
other words, he knows how to use the English 
language. He gives us the plain truth, free from 



unnecessary ornamentation. Therefore we say 
there are nine hundred pages of matter between 
the covers of this manual of four hundred and 
fifty pages. We cannot imagine a better manual 
for the hard- worked student; while its clear and 
practical teachings make it invaluable to the busy 
practitioner. The illustrations add much to the 
subject matter.— The National Medical Review, 
October, 1892. 



Barnes' System of Obstetric Medicine and Surgery. 

A System of Obstetric Medicine and Surgery, Theoretical and 
Clinical. For the Student and the Practitioner. By Kobert Barnes, M. D., Phys- 
ician to the General Lying-in Hospital, London, and Fancourt Barne?, M. D., Obstetric 
Physician to St. Thomas' Hospital, London. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 

Landis on Labor and the Lying-in Period. 

The Management of Labor, and of the Lying-in Period. 

By Henry G. Landis, A. M., M. D., Professor of Obstetrics and the Diseases of Women 
in Starling Medical College, Columbus, Ohio. In one handsome 12mo. volume of 334 
pages, with 28 illustrations. Cloth, $1.75. 



LEISHMAN'S SYSTEM OF MIDWIFERY, IN 
CLUDING THE DISEASES OF PREGNANCY 
AND THE PUERPERAL STATE. Fourth edi- 
tion. Octavo. 

PARRY ON EXTRA-UTERINE PREGNANCY: 
Its Clinical History, Diagnosis, Prognosis and 
Treatment. Octavo, 272 pag»s. Cloth, $2.50. 

RAMSBOTHAM'S PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised by the Author. With additions 
by W. V. Keating, M. D, Professor of Obstetrics, 
etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 



octavo volume of 640 pages, with 64 full- page 
plates and 43 woodcuts in the text, containing in 
all nearly 200 beautiful figures. Strongly bound 
in leather, with raised bands, $7. 

CHURCHILL ON THE PUERPERAL FEVER 
AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, $2.50. 

TANNER ON PREGNANCY. Octavo, 490 pages, 
colored plates, 16 cuts. Cloth, $4.25 

WINCKEL'S COMPLETE TREATISE ON THE 
PATHOLOGY AND TREATMENT OF CHILD- 
BED. For Students and Practitioners. Trans- 
lated from the second German edition, by J. R. 
Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



30 Dis. of Children, Obstetrics— (Cont'd), Manuals. 



Smith on Children— Seventh Edition. 

A Treatise on the Diseases of Infancy and Childhood. By 

J. Lewis Smith, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital 
Medical College, New York. New (seventh) edition, thoroughly revised and rewritten. 
In one handsome octavo volume of 881 pages, with 51 illus. Cloth, $4.50 ; leather, $5.50. 

We have always considered Dr. Smith's book as 
one of the very best on the subject. It has always 
been practical— a field book, theoretical where 
theory has been deduced from practical experi- 
ence. He takes his theory from the bedside and 
the pathological laboratory. The very practical 
character of this book has always appealed to us. 
It is characteristic of Dr. Smith in all his writings 
to collect whatever recommendations are found in 
medical literature, and his search has been wide. 
One seldom fails to find here a practical suggestion 
after search in other works has been in vain. In 
the seventh edition we note a variety of changes 
in accordance with the progress of the times. It 
still stands foremost as the American text-book. 
The literary style could not be excelled, its advice 



is always conservative and thorough, and the 
evidence of research has long since placed its 
author in the front rank of medical teachers.— 
The American Journal of the Medical Sciences, Dec. 
1891. 

In the present edition we notice that many of 
the chapters have been entirely rewritten. Full 
notice is taken of all the recent advances that 
have been made. Many diseases not previously 
treated of have received special chapters. The 
work is a very practical one. Especial care has 
been taken that the directions for treatment shall 
be particular and full. In no other work are such 
careful instructions given in the details of infant 
hygiene and the artificial feeding of infants. — 
Montreal Medical Journal. Feb. 1891. 



Herman's First Lines in Midwifery. 

First Lines in Midwifery: a Guide to Attendance on Natural 
Labor for Medical Students and Mid-wives. By G. Ernest Herman, M. B., 
F.E. CP., Obstetric Physician to the London Hospital. In one 12mo. volume of 198 
pages, with 80 illustrations. Cloth, $1.25. See Students Series of Manuals, below. 

This is a little book, intended for the medical I will prove valuable to the beginner in midwifery 
student and the educated midwife. The work j and could be read with advantage by the majority 
is written in a plain, simple style, and is as of practitioners, old and young.— The Medical 
much as possible devoid of technical terms. It j Fortnightly, April 15, 1892. 

Owen on Surgical Diseases of Children. 

Surgical Diseases of Children. By Edmund Owen, M. B., F. B. 0. S., 
Surgeon to the Children's Hospital, Great Ormond Street, London. In one 12mo. vol- 
ume of 525 pages, with 4 chromo-lithographic plates and 85 woodcuts. Cloth, $2.00. 

See Series of Clinical Manuals, below. 

honestly recommended to both students and 



One is immediately struck on reading this book 
with its agreeable style and the evidence it every- 
where presents of the practical familiarity of its 
author with his subject. The book may be 



practitioners. It is full of sound information, 
pleasantly given.— Annals of Surgery, May, 1886. 



Student's Series of Manuals. 



A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo. volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Luff's Manual of Chem- 
istry, $2 ; Herman's First Lines in Midwifery, $1.25 ; Treves' Manual of Surgery, by various writers, in 
three volumes, per set, $6; Bell's Comparative Anatomy and Physiology, $2; Gould's Surgical 
Diagnosis, 82 ; Robertson's Physiological Physics, $2 ; Bruce's Materia Medica and Therapeutics (5th edi- 
tion), $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's Dissectors' Man- 
ual, $1.50 ; Ralfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical 
Pathology, $2; and Klein's Elements of Histology (4th edition), $1.75. The following is in press: 
Pepper's Forensic Medicine. For separate notices see index on last page. 



Series of Clinical Manuals. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes contain about 550 pages and are freely illustrated by chromo-lithographs and wood- 
cuts. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Broadbent on 
the Pulse, $1.75; Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25; Marsh 
on the Joints, $2; Owen on Surgical Diseases of Children, $2; Morris on Surgical Diseases of the 
Kidney, $2.25 ; Pick on Fractures and Dislocations, $2; Butlin on the Tongue, $3.50; Treves on Intesti~ 
nal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. The following is in preparation: 
Lucas on Diseases of the Urethra. For separate notices see index on last page. 

Hartshorne's Conspectus of the Medical Sciences. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anat- 
omy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
By Henry Hartshorne, A. M., M. D., LL. D., lately Professor of Hygiene in the Uni- 
versity of Pennsylvania. Second edition, - thoroughly revised and greatly improved. In 
one large royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $425 ; leather, $5.00. 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
779 nages. Cloth, $5.25 ; leather, $G.25. 

WEST ON SOME DISORDERS OF THE NERV- 
OUS SYSTEM IN CHILDHOOD. In one small 
12mo. volume of 127 pages. Cloth, $1.00. 

LUDLOW'S MANUAL OF EXAMINATIONS. A 
Manual of Examinations upon Anatomy, Physi- 



ology, Surgery, Practice of Medicine, Obstetrics, 
Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical 
Formulary. By J. L. Ludlow, M. D., Consulting 
Physician to the Philadelphia Hospital, etc. 
Third edition, thoroughly revised, and greatly 
enlarged. In one 12mo. volume of 816 pages, 
with 370 illustrations. Cloth, $3.25; leather, $3.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street. Philadelphia. 



fledical Jurisprudence, Historical. 



31 



Taylor's Medical Jurisprudence —New Edition. Just Ready. 

A Manual of Medical Jurisprudence. By Alfred S. Taylor, M. D., 
Lecturer on Med. Jurisprudence and Chemistry in Guy's Hosp., London. New American 
from the 12th English edition. Thoroughly revised by Clark Bell, Esq., of the New- 
York Bar. In one octavo volume of 787 pages, with 56 illus. Cloth, $4.50 ; leather, $5.50. 

into the criminal courts. The editor has given to 
two professions a' reference-book to be relied upon. 
— The American Journal of the Medical Sciences, 



This is a complete revision of all former Ameri- 
can and English editions of this standard book. 
This edition contains a large amount of entirely 
new matter, many portions of the book having 
been rewritten by the editor. Many cases and 
authorities have been cited, and the citations 
brought down to the latest date. The book has 
long been a standard treatise on the subject of 
medical jurisprudence, and has gone through 
many editions— twelve English and eleven Ameri- 
can. Mr. Clark Bell has enlarged and improved 
what already seemed complete, by bringing his 
many citations of cases down to date to meet the 
present law ; and by adding much new matter he 
nas furnished the medical profession and the bar 
with a valuable book of reference, one to be relied 
upon in daily practice, and quite up to the present 
needs, owing to its exhaustive character. It 
would seem that the book is indispensable to the 
library of both physician and lawyer, and particu- 
larly the legal practitioner whose duties take him 



April, 1893. 

No library is complete without Taylor's Medical 
Jurisprudence, as its authority is accepted and un- 
questioned by the courts.— Buffalo Medical and 
Surgical Journal, June, 1893. 

There is no other work upon the subject which 
has been so uniformly recognized or so widely 
quoted and followed by courts in England and this 
country. This eleventh American edition is fully 
abreast with the most recent thought and knowl- 
edge. On the basis of his own researches, of the 
investigations of scientists throughout the world, 
and of the decisions of our own courts, Mr. Bell 
has incorporated in it a wealth of practical sug- 
gestion and instructive illustration which cannot 
fail to strengthen the hold it has so long had 
upon the profession. — The Criminal Law Magazine 
and Reporter, January, 1893. 



By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50; leather, $6.50. 

Lea's Superstition and Force.— New Edition. Just Ready. 

Superstition and Force: Essays on The Wager of Law, The 
"Wager of Battle, The Ordeal and Torture. By Henby Charles Lea, 
LL. D., New (4th) edition, revised and enlarged. Royal 12mo., 629 pages. Cloth, $2.75. 



Both abroad and at home the work has been 
accepted as a standard authority, and the author 
has endeavored by a complete revision and con- 
siderable additions to render it more worthy of 
the universal favor which has carried it to a 
fourth edition. The style is severe and simple, 
and yet delights with its elegance and reserved 
strength. Tne known erudition and fidelity of 
the author are guarantees that all possible origi- 
nal sources of information have been not only 
consulted but exhausted. The subject matter is 



handled in such an able and philosophic man- 
ner that to read and study it is a step toward 
liberal education. It is a comfort to read a book 
that is so thorough, well conceived and well done. 
We should like to see it made a text-book in our 
law schools and prescribed course for admission 
to the bar. — Legal Intelligencer, March 3, 1893. 

A work as remarkable for the wealth of histori- 
cal material treated as for the masterly style of 
the exposition.— London Saturday Review, Feb. 25, 
1893. 



By the same Author. 
Chapters from the Religious History of Spain.— In one 12mo. volume 
of 522 pages. Cloth $2.50. 



The width, depth and thoroughness of research 
which have earned Dr. Lea a high European place 
as the ablest historian the Inquisition has yet 
found are here applied to some side-issues of that 
great subject. We have only to say of this volume 



that it worthily complements the author's earlier 
studies in ecclesiastical history. His extensive 
and minute learning, much of it from inedited 
manuscripts in Mexico, appears on every page. — 
London Antiquary, Jan. 1891. 



In one 8vo. volume of 221 



By the same Author. 
The Formulary of the Papal Penitentiary. 

pages, with a frontispiece. Cloth, $2.50. Just Beady. 

By the Same Author. 
Studies in Church History. The Rise of the Temporal Power—Ben- 
efit of Clergy— Excommunication— The Early Church and Slavery. Sec- 
ond and revised edition. In one royal octavo volume of 605 pages. Cloth, $2.50. 



The author is preeminently a scholar; he takes 
up every topic allied with the leading theme and 
traces it out to the minutest detail with a wealth 
of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary, and 
the profuse citation of authorities and references 



makes the work particularly valuable to the student 
who desires an exhaustive review from original 
sources. In no other single volume is the develop- 
ment of the primitive church traced with so much 
clearness and with so definite a perception of 
complex or conflicting forces. — Boston Traveller. 



By the Same Author. 
An Historical Sketch of Sacerdotal Celibacy in the Christian 

Church. Second edition, enlarged. In one octavo volume of 685 pages. Cloth, $4.50. 

This subject has recently been treated with very 
great learning and with admirable impartiality bv 
an American author, Mr. Henry C. Lea, in his His- 
tory of Sacerdotal Celibacy, which is certainly one 
of the most valuable works that America has pro- 

duced. Since the great history of Dean Milman, j of European Morals, Chap. V. 
I know no work in English which has thrown I 



more light on the moral condition of the Middle 
Ages, and none which is more fitted to dispel the 
gross illusions concerning that period which posi- 
tive writers and writers of a certain ecclesiastical 
school have conspired to sustain.— Lecky's History 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Abbott's Bacteriology . 

Allen's Anatomy ..... 
American Journal of the Medical Sciences 
American Systems of Gynecology and Obstetrics 
American System of Practical Medicine . 
American System of Dentistry 
A shhurst's Surgery .... 
Ashwell on Diseases of Women 
Attfield's Chemistry .... 
Barlow's Practice of Medicine 
Barnes' System of Obstetric Medicine 
Bartbolow on Cholera 
Bartholow on Electricity 
Basham on Renal Diseases . 
Bell's Comparative Anatomy and Physiology 
Bellamy's Surgical Anatomy 
Berry on the Eye .... 
Billinsrs' National Medical Dictionary 
Blandford on Insanity 
Bloxam's Chemistry .... 
Broadbent on the Pulse 
Browne on Koch's Remedy . 
Browne on the Throat, Nose and Ear 
Bruce's Materia Medica and Therapeutics 
Brunton's Materia Medica and Therapeutics 
Bryant's Practice of Surgery . 
Bumstead and Taylor on Venereal, See Taylo 
Burnett on the Ear .... 
Butlin on the Tongue .... 
Carpenter on the Use and Abuse of Alcohol 
Carpenter's Human Physiology 
Carter & Frost's Ophthalmic Surgery 
Caspari's Pharmacy 
Chambers on Diet and Regimen 
Chapman's Human Physiology 
Charles' Physiological and Pathological Chem 
Churchill on Puerperal Fever 
Clarke and Lockwood's Dissectors' Manual 
Classen's Quantitative Analysis 
Cleland's Dissector .... 
Clouston on Insanity .... 
Clowes' Practical Chemistry 
Coats' Pathology .... 
Cohen's Applied Therapeutics 
Coleman's Dental Surgery . 
Condie on Diseases of Children 
Cornil on Syphilis .... 
Cullerier & Bumstead on Venereal 
Culver & Hayden on Venereal Diseases . 
Dalton on the Circulation 
Dalton's Human Physiology 
Davenport on Diseases of Women . 
Davis' Clinical Lectures 
Draper's Medical Physics . . 
Druitt's Modern Surgery 
Duncan on Diseases of Women 
Dungllson's Medical Dictionary 
Edes' Materia Medica and Therapeutics 
Edis on Diseases of Women . 
Ellis' Demonstrations of Anatomy 
Emmet's Gynaecology 
Erichsen's System of Surgery 
Farquharson's Therapeutics and Mat. Med. 
Field's Manual of Diseases of the Ear 
Flint on Auscultation and Percussion 
Flint on Phthisis .... 
Flint on Respiratory Organs 
Flint on the Heart 

Flint's Essays ..... 

Flint's Practice of Medicine 

Folsom's Laws of TJ. S. on Custody of Insane 

Foster's Physiology . . . • . 

Fotnergill's Handbook of Treatment 

Fownes' Elementary Chemistry 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages . 

Gant's Student's Surgery 

Gibbes' Practical Pathology 

Gould's Surgical Diagnosis . 

Gray on Nervous and Mental Diseases . 

Gray's Anatomy . . ... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

Habershon on the Abdomen 

Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hardaway on the Skin 

Hare's Practical Therapeutics 

Hare's System of Practical Therapeutics 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Herman's First Lines in Midwifery 

Hermann's Experimental Pharmacology 

Hill on Syphilis ..... 

Hillier's Handbook of Skin Diseases 

Hirst & Piersol on Human Monstrosities 

Hoblyn's Medical Dictionary 

Hodge on Women 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

Holmes' Principles and Practice of Surgery 

Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever 

Hutchinson on Syphilis 

Hyde on the Diseases of the Skin . 

Jackson on the Skin . 

Jamieson on the Skin 

Joues (C. Handheld) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

King's Manual of Obstetrics . 

Klein's Histology 

Landis on Labor 



6 
23 
4 
18 
9 

15, 30 
17 
17 
12,30 
13 
21 
. 25 
24 
20,30 
7 



18,30 

29 



16 
19 
30 

18,30 
14 

22,30 
20 
17 
29 
24 



La Roche on Pneumonia, Malaria, etc. . . 17 

La Roche on Yellow Fever . . . .13 

Laurence and Moon's Ophthalmic Surgery . 23 
Lawson on the Eye, Orbit and Eyelid . . 23 
Lea's Chapters from Religious History of Spain 31 
Lea's Formulary of t he Papal Penitentiary . 31 
Lea's Sacerdotal Celibacy . . . .31 

Lea's Studies in Church History . .31 
Lea's Superstition and Force . . .31 
Lee on Syphilis . . . . 15 

Lehmann f s Chemical Physiology ... 7 
Leishman's Midwifery .... 29 

Lucas on Diseases of the Urethra . 
Ludlow's Manual of Examinations 
Luff's Manual of Chemistry 
Lyman's Practice of Medicine . . .14 
Lyons on Fe\er . . . . .13 

Maisch's Organic Materia Medica . . .11 
Marsh on the Joints . . .22, 30 

May on Diseases of Women . 
Medical News ...... 1 

Medical News Physicians' Ledger ... 2 
Medical News Visiting List . . .2 
Miller's Practice of Surgery .... 20 

Miller's Principles of Surgery ... 20 
Morris on Diseases of the Kidney . . . 24, 30 
Musser's Medical Diagnosis .... 15 

National Dispensatory . 11 

National Medical Dictionary . . 4 

Nettleship on Diseases of the Eye . 
Norris and Oliver on the Eye 
Owen on Diseases of Children 
Parrish's Practical Pharmacy 
Parry on Extra-Uterine Pregnancy 
Parvin's Midwifery 
Pavy on Digestion and its Disorders 
Payne's General Pathology . 
Pepper's Forensic Medicine . 
Pepper's Surgical Pathology 
Pepper's System of Medicine 
Pick on Fractures and Dislocations 
Pirrie's System of Surgery . 
Playfair on Nerve Prostration and Hysteria 
Playfair's Midwifery . 
Politzer on the Ear 
Power's Human Physiology . 
Purdy on Bright's Disease and Allied Affections 
Pye-Smith on the Skin 
Quiz Series 

Ralfe's Clinical Chemistry 
Ramsbotham on Parturition 
Reichert's Physiology . . . . 7 

Remsen's Theoretical Chemistry ... 10 
Reynolds' System of Medicine ... 13 
Richardson's Preventive Medicine . . 16 
Roberts on Urinary Diseases 
Roberts' Compend of Anatomy 7 
Roberts' Surgery ... 20 

Robertson's Physiological Physics . . 7,30 
Ross on Nervous Diseases . . . .18 
Savage on Insanity, including Hysteria . . 18,30 
Schafer's Essentials of Histology, . . 18 

Schofield's Physiology •••••,! 
Schreiber on Massage . . ... 16 
Seiler on the Throat, Nose and Naso-Pharynx 17 
Senn's Surgical Bacteriology ... 19 
Series of Clinical Manuals . 
Simon's Manual of Chemistry 
Slade on Diphtheria 
Smith (Edward) on Consumption . 
Smith (J. Lewis) on Children 
Smi th's Operative Surgery 
Stille on Cholera 

Stille & Maisch's National Dispensatory 
Still6's Therapeutics and Materia Medica 
Stimson on Fractures and Dislocations 
Stimson's Operative Surgery 
Students' Quiz Series .... 
Students' Series of Manuals . 
Sturges' Clinical Medicine . 
Sutton on the Ovaries and Fallopian Tubes 
Sutton on Tumors .... 
Tait's Diseases of Women and Abdom. Surgery 
Tanner on Signs and Diseases of Pregnancy 
Tanner's Manual of Clinical Medicine . 
Taylor's Atlas of Venereal and Skin Diseases 
Tavlor on Poisons .... 
Taylor on Venereal Diseases 
I Taylor's Medical Jurisprudence 
I Thomas & Munde on Diseases of Women 
Thompson on Stricture 
Thompson on Urinary Organs 
Todd on Acute Diseases 
Treves' Manual of Surgery . 
Treves on Intestinal Obstruction . . ' n >yS 
Treves' Operative Surgery . . • £ 
Treves' Student's Handbook of Surg. Operations, 21 
Treves' Surgical Applied Anatomy 
Tukeon the Influence of Mind on the Body . 
Vaughan & Novy's Ptomaines and Leucomames 
Visiting List, The Medical News 
Walshe on the Heart . 
Watson's Practice of Physic . 
Wells on the Eye 
West on Diseases of Women 
West on Nervous Disorders in Childhood 
Wharton's Minor Surgery and Bandaging 
Whitla's Dictionary of Treatment 
Williams on Consumption . . .. 
Wilson's Handbook of Cutaneous Medicine . -» 
Wilson's Human Anatomy . . _.■„..; 
Winckel on Pathol, and Treatment of Childbed i» 
Winder's Organic Chemistry . . . * 
Year-Books of Treatment for 86. '87. '91, 'S2, 93. 14 
Yco's Medical Treatment, or Clinical Therapeutics, 16 
Yeo on Food in Health and Disease . . lb.tfJ 
Young's Orthopaedic Surgery 



15 



6,30 
17 
10 
2 
15 
13 
23 
27 
30 
21 
15 
17 



•20 



i 



4 



